Provider Demographics
NPI:1144312372
Name:WILSON, CLAYTON D (MD)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 N LOCUST AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-2706
Mailing Address - Country:US
Mailing Address - Phone:931-762-0531
Mailing Address - Fax:931-762-0998
Practice Address - Street 1:1009 N LOCUST AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2706
Practice Address - Country:US
Practice Address - Phone:931-762-0531
Practice Address - Fax:931-762-0998
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNE04256Medicare UPIN
TNPENDINGMedicaid