Basic Information
| Provider Information | |||||||||
| NPI: | 1033716568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | MI | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSED | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 AUSTIN STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187627633 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 AUSTIN STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187627633 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2020 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.