Provider Demographics
NPI:1437185923
Name:WILLIAM C. WILSON D.O. P.A.
Entity Type:Organization
Organization Name:WILLIAM C. WILSON D.O. P.A.
Other - Org Name:WILSON FAMILY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-476-0003
Mailing Address - Street 1:5190 BAYOU BLVD
Mailing Address - Street 2:BLDG 2
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2194
Mailing Address - Country:US
Mailing Address - Phone:850-476-0003
Mailing Address - Fax:850-476-4724
Practice Address - Street 1:5190 BAYOU BLVD
Practice Address - Street 2:BLDG 2
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2194
Practice Address - Country:US
Practice Address - Phone:850-476-0003
Practice Address - Fax:850-476-4724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80218Medicare ID - Type UnspecifiedMC ID