Healthcare Provider Details

I. General information

NPI: 1720128366
Provider Name (Legal Business Name): CHARLES LEONARD WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 TELEGRAPH RD
SANTA FE SPRINGS CA
90670-3674
US

IV. Provider business mailing address

PO BOX 3210
LA HABRA CA
90632-3210
US

V. Phone/Fax

Practice location:
  • Phone: 562-949-8455
  • Fax: 562-949-4807
Mailing address:
  • Phone: 714-870-8748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA18240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: