Provider Demographics
NPI:1164484267
Name:WILSON, CHARLES STOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STOTT
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 WEST STATE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650
Mailing Address - Country:US
Mailing Address - Phone:217-243-1865
Mailing Address - Fax:217-243-6765
Practice Address - Street 1:814 WEST STATE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650
Practice Address - Country:US
Practice Address - Phone:217-243-1865
Practice Address - Fax:217-243-6765
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036043460208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036043460Medicaid
D86550Medicare UPIN
ILL80928Medicare PIN
IL219550Medicare ID - Type Unspecified