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NPI Code Detail

MEDICARE: CHARLES V WILSON M D P A

MEDICARE: CHARLES V WILSON M D P A
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
1207V00000XObstetrics & Gynecology Physician

General Provider Information

NPI Number : 1629248422
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHARLES V WILSON M D P A
Provider Business Mailing Address
First Line : 3525A US HIGHWAY 17
Second Line :
City : FLEMING ISLAND
State : FL
Zip : 32003-7122
Country : US
Telephone Number : 904-215-3880
Fax Number : 904-215-3883
Provider Business Practice Location Address
First Line : 3525A US HIGHWAY 17
Second Line :
City : FLEMING ISLAND
State : FL
Zip : 32003-7122
Country : US
Telephone Number : 904-215-3880
Fax Number : 904-215-3883
Authorized Official
Title or Position : PRESIDENT
Name : DR. CHARLES VAN BUREN WILSON JR.
Credential : MD
Telephone Number : 904-215-3880
Provider Enumeration Date : 03/07/2008
Last Update Date : 11/09/2009

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