Provider Demographics
NPI:1760470439
Name:WILSON, THOMAS LAURENCE (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LAURENCE
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:PO BOX 5487
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-5487
Mailing Address - Country:US
Mailing Address - Phone:903-792-1216
Mailing Address - Fax:903-614-5299
Practice Address - Street 1:2602 SAINT MICHAEL DR
Practice Address - Street 2:SUITE 201A
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2387
Practice Address - Country:US
Practice Address - Phone:903-792-1216
Practice Address - Fax:903-614-5299
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-07
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7024207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DF12OtherBC/BS
AR11368001Medicaid
TX097982501Medicaid
AR89358OtherBLUE CROSS
AR11368001Medicaid
TX00DF12OtherBC/BS