Provider Demographics
NPI:1477516938
Name:WILSON, LOUIS J (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:J
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 1:1104 BROOK AVENUE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5049
Mailing Address - Country:US
Mailing Address - Phone:940-687-6870
Mailing Address - Fax:940-687-6871
Practice Address - Street 1:1104 BROOK AVENUE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5049
Practice Address - Country:US
Practice Address - Phone:940-687-6870
Practice Address - Fax:940-687-6871
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3534207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029658401Medicaid
TX0013BQMedicare ID - Type Unspecified
TX029658401Medicaid