Provider Demographics
NPI:1073569984
Name:WILSON, MARTIN CONWAY (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:CONWAY
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 1:305 HARBISON RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5202
Mailing Address - Country:US
Mailing Address - Phone:610-688-2347
Mailing Address - Fax:
Practice Address - Street 1:155 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1740
Practice Address - Country:US
Practice Address - Phone:610-993-8083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052792L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA528215QQWMedicare ID - Type Unspecified
PAF89469Medicare UPIN