Provider Demographics
NPI:1699702910
Name:WILSON, CHARLES V JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:V
Last Name:WILSON
Suffix:JR
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 1:3525A US HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7122
Mailing Address - Country:US
Mailing Address - Phone:904-215-3880
Mailing Address - Fax:904-215-3883
Practice Address - Street 1:3525A US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-7122
Practice Address - Country:US
Practice Address - Phone:904-215-3880
Practice Address - Fax:904-215-3883
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAW 1670757174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065705100Medicaid
FL03-0514915OtherEIN
FL065705100Medicaid
FLD62429Medicare UPIN