Provider Demographics
NPI:1396866281
Name:ISABELLE PONGE WILSON MD PC
Entity Type:Organization
Organization Name:ISABELLE PONGE WILSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ISABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PONGE WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-679-4134
Mailing Address - Street 1:50 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3075
Mailing Address - Country:US
Mailing Address - Phone:212-679-4134
Mailing Address - Fax:212-679-7079
Practice Address - Street 1:50 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3075
Practice Address - Country:US
Practice Address - Phone:212-679-4134
Practice Address - Fax:212-679-7079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198244207N00000X, 207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEN721Medicare PIN