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
State | License ID | Taxonomies |
---|---|---|
NY | 1344691 | 207NS0135X |
NY | 134469 | 207ND0101X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ND0101X | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No | 207NS0135X | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | B71670 | Medicare UPIN | |
NY | 048511 | Medicare PIN |