Provider Demographics
NPI:1285031492
Name:WILSON, STEPHEN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JAY
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 1:954 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1208
Mailing Address - Country:US
Mailing Address - Phone:516-241-3770
Mailing Address - Fax:
Practice Address - Street 1:954 MADISON PL
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1208
Practice Address - Country:US
Practice Address - Phone:516-241-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121280207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC08036Medicare UPIN