MEDICARE: CHARLES J WILSON M.D.

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	174400000X	Specialist	16578	MS

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
2	203211285	OTHER	MS	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1558311431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES J WILSON M.D.

Provider Business Mailing Address
First Line	:	1137 OCEAN SPRINGS RD
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-3421
Country	:	US
Telephone Number	:	228-875-8291
Fax Number	:	877-504-3044

Provider Business Practice Location Address
First Line	:	1137 OCEAN SPRINGS RD
Second Line	:
City	:	OCEAN SPRINGS
State	:	MS
Zip	:	39564-3421
Country	:	US
Telephone Number	:	228-875-8291
Fax Number	:	877-504-3044

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	10/05/2015

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