Healthcare Provider Details

I. General information

NPI: 1790799807
Provider Name (Legal Business Name): CHARLES R WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 MORRIS RD W
SOUR LAKE TX
77659-9774
US

IV. Provider business mailing address

327 MORRIS RD W
SOUR LAKE TX
77659-9774
US

V. Phone/Fax

Practice location:
  • Phone: 409-753-2577
  • Fax:
Mailing address:
  • Phone: 409-753-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH8516
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: