Provider Demographics
NPI:1083159230
Name:WILSON, DEMBE
Entity Type:Individual
Prefix:
First Name:DEMBE
Middle Name:
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 1:2700 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2547
Mailing Address - Country:US
Mailing Address - Phone:914-607-5730
Mailing Address - Fax:914-457-1195
Practice Address - Street 1:3030 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2574
Practice Address - Country:US
Practice Address - Phone:914-682-6435
Practice Address - Fax:914-681-3115
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040668174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04783024Medicaid