Provider Demographics
NPI:1497066518
Name:WILSON, CHARLES OMAR JR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:OMAR
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:747 REDFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143
Mailing Address - Country:US
Mailing Address - Phone:706-692-0812
Mailing Address - Fax:706-692-0812
Practice Address - Street 1:175 SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143
Practice Address - Country:US
Practice Address - Phone:706-253-4673
Practice Address - Fax:706-253-4675
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA050283207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology