Provider Demographics
NPI:1730275322
Name:WILSON, CHARLES FREDERICK (DPM)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-3358
Mailing Address - Country:US
Mailing Address - Phone:301-384-7687
Mailing Address - Fax:
Practice Address - Street 1:13100 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-3358
Practice Address - Country:US
Practice Address - Phone:301-384-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD644213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD442618OtherMEDICARE NUMBER
MD2700037OtherEVERCARE NUMBER
MD480002354OtherRAILROAD MEDICARE NUMBER
MD8772OtherBC/BS FEDERAL
DC036181300Medicaid
MD442618Medicare ID - Type UnspecifiedMEDICARE NUMBER
MD37045-8100Medicaid