Provider Demographics
NPI:1295781359
Name:WILSON, CHARLES A (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-533-6836
Mailing Address - Fax:407-232-9316
Practice Address - Street 1:6360 BOULDER HWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-7301
Practice Address - Country:US
Practice Address - Phone:725-228-4520
Practice Address - Fax:877-889-5390
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1295781359Medicaid
NVPENDINGMedicare PIN
NVV110248OtherSMA MEDICARE
HIH23226Medicare UPIN
HIH102651Medicare PIN