Provider Demographics
NPI:1356867014
Name:FREDERIC J. WILSON, MD, PLLC
Entity type:Organization
Organization Name:FREDERIC J. WILSON, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZE OFFICE OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-858-7474
Mailing Address - Street 1:800 US HWY 290 WEST BLDG B
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 US HWY 290 W BLDG B
Practice Address - Street 2:SUITE 400
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-4191
Practice Address - Country:US
Practice Address - Phone:512-858-7474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty