Provider Demographics
NPI:1043320559
Name:ANTOINE, WILSON (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:ANTOINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3721
Mailing Address - Country:US
Mailing Address - Phone:973-372-4937
Mailing Address - Fax:973-372-4937
Practice Address - Street 1:52 UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-3721
Practice Address - Country:US
Practice Address - Phone:973-372-4937
Practice Address - Fax:973-372-4937
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44539207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1147803Medicaid
NJD06493Medicare UPIN
NJAN450261Medicare ID - Type Unspecified