MEDICARE: DR. CHARLES A WILSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DO1782	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295781359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES A WILSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 616788
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32861-6788
Country	:	US
Telephone Number	:	407-533-6836
Fax Number	:	407-232-9316

Provider Business Practice Location Address
First Line	:	6360 BOULDER HWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-7301
Country	:	US
Telephone Number	:	725-228-4520
Fax Number	:	877-889-5390

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	11/14/2024

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Directions to “ DR. CHARLES A WILSON D.O.” Practice Location

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