Provider Demographics
NPI:1629955356
Name:WILSON, CALEB T
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:T
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 RIKISHA LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3537
Mailing Address - Country:US
Mailing Address - Phone:409-338-6124
Mailing Address - Fax:
Practice Address - Street 1:1440 RIKISHA LN
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3537
Practice Address - Country:US
Practice Address - Phone:409-338-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNONE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program