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General NPI Number Information
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NPI Number | 1609319458
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Entity Type | Organization
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Legal Business Name | NACOGDOCHES INTERNAL MEDICINE PLLC
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Dates
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Enumeration Date | 11/28/2016
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Last Update Date | 05/21/2018
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Provider Practice Location Address
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Address Line | 412 NORTH ST STE E
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City | NACOGDOCHES
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State | TX
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Zip | 75961
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Country | US
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Telephone | 936-560-1812
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Fax | 936-560-3070
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Provider Business Mailing Address
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Address Line | 412 NORTH ST STE E
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City | NACOGDOCHES
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State | TX
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Zip | 75961-5070
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Country | US
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Telephone | 936-560-1812
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Fax | 936-560-3070
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WALTER BRAD WILSON
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Credential | M.D.
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Telephone | 936-560-1812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | H3293
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License Number State | TX
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