1760470439 NPI number — THOMAS LAURENCE WILSON MD

Table of content: DAVID NICHOL BCBA (NPI 1407261738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760470439 NPI number — THOMAS LAURENCE WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
THOMAS
Provider Middle Name:
LAURENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760470439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75505-5487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-792-1216
Provider Business Mailing Address Fax Number:
903-614-5299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2602 SAINT MICHAEL DR
Provider Second Line Business Practice Location Address:
SUITE 201A
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-1216
Provider Business Practice Location Address Fax Number:
903-614-5299
Provider Enumeration Date:
10/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  G7024 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00DF12 . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 11368001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 097982501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89358 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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