Active NPI
Mark Davis Wilson, M.D.
- Pediatrics Physician
- Tifton, GA
National Provider Identifier
1003132754
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- 069737
- Practice address
- 215 12TH St W
Tifton, GA 31794-3923 - Phone
- (229) 396-5335
- Fax
- (229) 396-5330
- NPI assigned
- Apr 19, 2010
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 069737 | GA | Primary |
Addresses
Primary practice location
215 12TH St W
Tifton, GA 31794-3923
Mailing address
215 12TH St W
Tifton, GA 31794-3923
Phone (229) 396-5335
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 69737 | Other | GA | LICENSE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Tiftarea Pediatrics | Pediatrics | Current | Accepting new patients |
| Careconnect Health, Inc. | Current | Accepting new patients | |
| Careconnect Health, Inc. | Current | Accepting new patients |
Locations
510 Alston St
Ste B
Richland, GA 31825
Phone (229) 887-3324
215 12th St W
Tifton, GA 31794
Phone (229) 396-5335
1909 US Highway 82 W
Ste 34
Tifton, GA 31793
Phone (229) 445-3509
Interoperability endpoints
- https://fhir4.healow.com/fhir/r4/CIJICD/Endpoint/CIJICD
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Federally Qualified Health Center (FQHC)
- Sylvester, GA
- NPI 1811874696
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1271635200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1678147200000",
"number": "1003132754",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "215 12TH ST W",
"city": "TIFTON",
"state": "GA",
"postal_code": "317943923",
"telephone_number": "229-396-5335",
"fax_number": "229-396-5330"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "215 12TH ST W",
"city": "TIFTON",
"state": "GA",
"postal_code": "317943923",
"telephone_number": "229-396-5335",
"fax_number": "229-396-5330"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "MARK",
"middle_name": "DAVIS",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2010-04-19",
"last_updated": "2023-03-07",
"certification_date": "2022-10-19",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "GA",
"license": "069737",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LICENSE",
"identifier": "69737",
"state": "GA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Tifton, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.