Provider Demographics
NPI:1992842736
Name:WILSON, CHARLES CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CLINTON
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11001 BRIARLYNN CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-2331
Mailing Address - Country:US
Mailing Address - Phone:703-425-5352
Mailing Address - Fax:703-425-0842
Practice Address - Street 1:2025 E MAIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7069
Practice Address - Country:US
Practice Address - Phone:804-591-2890
Practice Address - Fax:804-591-2896
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101058559207Q00000X
CAG22781207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine