Provider Demographics
NPI:1558311431
Name:WILSON, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
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 1:1137 OCEAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3421
Mailing Address - Country:US
Mailing Address - Phone:228-875-8291
Mailing Address - Fax:877-504-3044
Practice Address - Street 1:1137 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-875-8291
Practice Address - Fax:877-504-3044
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16578174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123305Medicaid
MS203211285OtherTAX IDENTIFICATION NUMBER
MS203211285OtherTAX IDENTIFICATION NUMBER
MS0123305Medicaid