Provider Demographics
NPI:1457667487
Name:WILSON, BRUCE LEONARD (MD, MSPH)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEONARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, MSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2073 KLOCKNER RD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690
Mailing Address - Country:US
Mailing Address - Phone:609-584-1212
Mailing Address - Fax:609-584-0103
Practice Address - Street 1:2073 KLOCKNER RAOD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08690
Practice Address - Country:US
Practice Address - Phone:609-584-1212
Practice Address - Fax:609-584-0103
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09945200207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22-3052989OtherTAX ID#