Provider Demographics
NPI:1245237288
Name:WILSON, BRUMMITTE DALE (MD)
Entity Type:Individual
Prefix:
First Name:BRUMMITTE
Middle Name:DALE
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 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:17 LONG AVE STE 200
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-6200
Practice Address - Country:US
Practice Address - Phone:716-648-2770
Practice Address - Fax:716-646-4642
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1344691207NS0135X
NY134469207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB71670Medicare UPIN
NY048511Medicare PIN