MEDICARE: THOMAS LAURENCE WILSON MD

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	207V00000X	Obstetrics & Gynecology Physician	G7024	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00DF12	OTHER	TX	BC/BS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	89358	OTHER	AR	BLUE CROSS

General Provider Information

NPI Number	:	1760470439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS LAURENCE WILSON MD

Provider Business Mailing Address
First Line	:	2602 SAINT MICHAEL DR STE 201A
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2387
Country	:	US
Telephone Number	:	903-792-1216
Fax Number	:	903-614-5299

Provider Business Practice Location Address
First Line	:	2602 SAINT MICHAEL DR
Second Line	:	SUITE 201A
City	:	TEXARKANA
State	:	TX
Zip	:	75503-2387
Country	:	US
Telephone Number	:	903-792-1216
Fax Number	:	903-614-5299

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	01/09/2026

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Directions to “ THOMAS LAURENCE WILSON MD” Practice Location

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