Provider Demographics
NPI:1154338382
Name:WILSON, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:808 BUFFALO ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1112
Mailing Address - Country:US
Mailing Address - Phone:434-392-3375
Mailing Address - Fax:434-392-3604
Practice Address - Street 1:808 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1112
Practice Address - Country:US
Practice Address - Phone:434-392-3375
Practice Address - Fax:434-392-3604
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101031065207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
276995OtherSOUTHERN HEALTH
VA004129OtherBLUE CROSS BLUE SHIELD
B05841Medicare UPIN