Provider Demographics
NPI:1679502108
Name:WILSON, WILLIAM CARL (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:CARL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 BAYOU BLVD
Mailing Address - Street 2:SUITE 49A
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2673
Mailing Address - Country:US
Mailing Address - Phone:850-476-0003
Mailing Address - Fax:850-476-4724
Practice Address - Street 1:4400 BAYOU BLVD
Practice Address - Street 2:SUITE 49A
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2673
Practice Address - Country:US
Practice Address - Phone:850-476-0003
Practice Address - Fax:850-476-4724
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5519207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061538200Medicaid
FL592966180OtherPRACTICE TAX ID
FL061538200Medicaid
FLE81194Medicare UPIN