Provider Demographics
NPI:1407931975
Name:WILSON, CHRISTINE B (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211
Mailing Address - Street 2:
Mailing Address - City:SO PLYMOUTH
Mailing Address - State:NY
Mailing Address - Zip Code:13844-0211
Mailing Address - Country:US
Mailing Address - Phone:607-334-7825
Mailing Address - Fax:
Practice Address - Street 1:4 NEWTON AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-1153
Practice Address - Country:US
Practice Address - Phone:607-337-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177130208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01286891Medicaid
NYF09004Medicare UPIN
NYRA5738Medicare ID - Type Unspecified