Provider Demographics
NPI:1760691752
Name:WILSON, CHRISTOPHER M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
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 1:2449 HOSPITAL DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2399
Mailing Address - Country:US
Mailing Address - Phone:318-841-4004
Mailing Address - Fax:318-841-4008
Practice Address - Street 1:2449 HOSPITAL DR
Practice Address - Street 2:SUITE 280
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2399
Practice Address - Country:US
Practice Address - Phone:318-841-4004
Practice Address - Fax:318-841-4008
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200947208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4P065OtherMEDICARE PTAN
LA1092100Medicaid