Provider Demographics
NPI:1073541397
Name:WILSON, SAMUEL A (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:WILSON
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 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:5925 KISSENA BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5547
Practice Address - Country:US
Practice Address - Phone:718-670-6100
Practice Address - Fax:718-670-6110
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183473207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9255EXMedicare ID - Type Unspecified
NYE98903Medicare UPIN