Provider Demographics
NPI:1376626309
Name:WILSON, CHARLES L (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
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 1:5402 47TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2927
Mailing Address - Country:US
Mailing Address - Phone:206-525-4090
Mailing Address - Fax:206-985-2875
Practice Address - Street 1:5402 47TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2927
Practice Address - Country:US
Practice Address - Phone:206-525-4090
Practice Address - Fax:206-985-2875
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016624208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7062144Medicaid
WA7062144Medicaid