Individual
GARY WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2323 W FRONT ST, TYLER, TX 75702-7704
(903) 597-1351
Mailing address
2323 W FRONT ST, TYLER, TX 75702-7704
(903) 597-1351
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
F4694
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00RY81
BCBS
TX
05
—
131123505
—
TX
Enumeration date
11/09/2006
Last updated
12/20/2012
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