Provider Demographics
NPI:1295933471
Name:WILSON, CHARLES RICHARD (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
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 1:1400 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5315
Mailing Address - Country:US
Mailing Address - Phone:406-454-2171
Mailing Address - Fax:
Practice Address - Street 1:6 WOODLAND RD STE 205
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9501
Practice Address - Country:US
Practice Address - Phone:707-963-6111
Practice Address - Fax:707-963-6161
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT47551208600000X
CAC164914208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03026446Medicaid
VT1022802Medicaid
VT1022802Medicaid