Provider Demographics
NPI:1619179611
Name:RICHARD D. WILSON, M.D.
Entity Type:Organization
Organization Name:RICHARD D. WILSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-269-1760
Mailing Address - Street 1:2411 E LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-5912
Mailing Address - Country:US
Mailing Address - Phone:817-269-1760
Mailing Address - Fax:817-613-0020
Practice Address - Street 1:2411 E LAKE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-5912
Practice Address - Country:US
Practice Address - Phone:817-269-1760
Practice Address - Fax:817-613-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00138KMedicare ID - Type UnspecifiedGROUP NUMBER
TXC23638Medicare UPIN