Basic Information
| Provider Information | |||||||||
| NPI: | 1720128366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3210 | ||||||||
| Address2: | |||||||||
| City: | LA HABRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906323210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148708748 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11721 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906703674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629498455 | ||||||||
| FaxNumber: | 5629494807 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A18240 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.