Provider Demographics
NPI:1275518524
Name:WILSON, CARMEN R (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 LIVE OAK ST
Practice Address - Street 2:EAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6109
Practice Address - Country:US
Practice Address - Phone:214-266-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139450402Medicaid
TX139450404Medicaid
TX139450410Medicaid
TX139450416Medicaid
TX139450408Medicaid
TX139450411Medicaid
TX139450412Medicaid
TX139450406Medicaid
TX139450415Medicaid
TX139450403Medicaid
TX139450414Medicaid
TX139450409Medicaid
TX89G970OtherBLUE CROSS BLUE SHIELD
TX139450403Medicaid
TX139450402Medicaid