Provider Demographics
NPI:1720393937
Name:CHARLES A. WILSON D.O., LLC
Entity Type:Organization
Organization Name:CHARLES A. WILSON D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:808-744-1906
Mailing Address - Street 1:91-2139 FORT WEAVER RD
Mailing Address - Street 2:SUITE 213
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3607
Mailing Address - Country:US
Mailing Address - Phone:808-677-8008
Mailing Address - Fax:808-677-8007
Practice Address - Street 1:91-2139 FORT WEAVER RD
Practice Address - Street 2:SUITE 213
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3607
Practice Address - Country:US
Practice Address - Phone:808-677-8008
Practice Address - Fax:808-677-8007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS 1154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI597081Medicaid
HIH102651Medicare PIN
HIH23226Medicare UPIN