MEDICARE: DR. CHARLES R WILSON D.O.

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	207Q00000X	Family Medicine Physician	H8516	TX

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

General Provider Information

NPI Number	:	1790799807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES R WILSON D.O.

Provider Business Mailing Address
First Line	:	327 MORRIS RD W
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-9774
Country	:	US
Telephone Number	:	409-753-2577
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 MORRIS RD W
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-9774
Country	:	US
Telephone Number	:	409-753-2577
Fax Number	:

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

Provider Enumeration Date	:	07/27/2006
Last Update Date	:	05/01/2013

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