Nacogdoches Internal Medicine PLLC

Primary specialty

Internal Medicine PhysicianTaxonomy code 207R00000X

License

H3293 Issued in TX

Legal business name

NACOGDOCHES INTERNAL MEDICINE PLLC

Practice address

412 North St Ste E
Nacogdoches, TX 75961

Phone

(936) 560-1812

Fax

(936) 560-3070

NPI assigned

Nov 28, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Walter Brad Wilson, M.D.

Title

President

Phone

(936) 560-1812

Specialties & licenses 1

Addresses

Other identifiers 2

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1480291200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1526860800000",
    "number": "1609319458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "412 NORTH ST STE E",
            "city": "NACOGDOCHES",
            "state": "TX",
            "postal_code": "759615070",
            "telephone_number": "936-560-1812",
            "fax_number": "936-560-3070"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "412 NORTH ST STE E",
            "city": "NACOGDOCHES",
            "state": "TX",
            "postal_code": "75961",
            "telephone_number": "936-560-1812",
            "fax_number": "936-560-3070"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NACOGDOCHES INTERNAL MEDICINE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-11-28",
        "last_updated": "2018-05-21",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "WALTER",
        "authorized_official_middle_name": "BRAD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "936-560-1812",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "TX",
            "license": "H3293",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "377530601",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "113906502",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Internal Medicine Physician in Nacogdoches, TX
• Providers in Nacogdoches, TX by specialty
• Internal Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.