Provider Demographics
NPI:1114094612
Name:WIXSOM, GEORGE JORY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JORY
Last Name:WIXSOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W. HAWTHORNE AVE.
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598
Mailing Address - Country:US
Mailing Address - Phone:516-569-6600
Mailing Address - Fax:516-374-2261
Practice Address - Street 1:20 W PARK AVE
Practice Address - Street 2:SUITE 310B
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-2033
Practice Address - Country:US
Practice Address - Phone:516-978-1612
Practice Address - Fax:516-374-2261
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224685-12084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02406628Medicaid
NY02406628Medicaid