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General NPI Number Information
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NPI Number | 1619179611
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Entity Type | Organization
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Legal Business Name | RICHARD D. WILSON, M.D.
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Dates
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Enumeration Date | 06/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2411 E LAKE DR
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City | WEATHERFORD
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State | TX
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Zip | 76087-5912
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Country | US
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Telephone | 817-269-1760
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Fax | 817-613-0020
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Provider Business Mailing Address
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Address Line | 2411 E LAKE DR
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City | WEATHERFORD
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State | TX
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Zip | 76087-5912
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Country | US
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Telephone | 817-269-1760
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Fax | 817-613-0020
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. RICHARD D WILSON
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Credential | M.D.
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Telephone | 817-269-1760
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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 | G3095
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License Number State | TX
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