Provider Demographics
NPI:1265530984
Name:WILSON, FRED EUGENE (MD)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:EUGENE
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 780
Mailing Address - Street 2:908 NORTH EDMONDS
Mailing Address - City:MC CRORY
Mailing Address - State:AR
Mailing Address - Zip Code:72101-0780
Mailing Address - Country:US
Mailing Address - Phone:870-731-1100
Mailing Address - Fax:870-731-1019
Practice Address - Street 1:908 NORTH EDMONDS
Practice Address - Street 2:
Practice Address - City:MC CRORY
Practice Address - State:AR
Practice Address - Zip Code:72101-0780
Practice Address - Country:US
Practice Address - Phone:870-731-1100
Practice Address - Fax:870-731-1019
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2025-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134056002Medicaid
AR134474729Medicaid
AR134474729Medicaid