Provider Demographics
NPI:1609319458
Name:NACOGDOCHES INTERNAL MEDICINE PLLC
Entity Type:Organization
Organization Name:NACOGDOCHES INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:BRAD
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-560-1812
Mailing Address - Street 1:412 NORTH ST STE E
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-5070
Mailing Address - Country:US
Mailing Address - Phone:936-560-1812
Mailing Address - Fax:936-560-3070
Practice Address - Street 1:412 NORTH ST STE E
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961
Practice Address - Country:US
Practice Address - Phone:936-560-1812
Practice Address - Fax:936-560-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX377530601Medicaid
TX113906502Medicaid
TX00A62KMedicare PIN