Provider Demographics
NPI:1477519817
Name:WILSON, BARCLAY M (DO)
Entity Type:Individual
Prefix:
First Name:BARCLAY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:PA
Mailing Address - Zip Code:17847-1113
Mailing Address - Country:US
Mailing Address - Phone:570-742-8511
Mailing Address - Fax:570-742-9134
Practice Address - Street 1:130 S FRONT ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:PA
Practice Address - Zip Code:17847-1113
Practice Address - Country:US
Practice Address - Phone:570-742-8511
Practice Address - Fax:570-742-9134
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS002757L208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006688790001Medicaid
PA069109Medicare PIN
PAD77381Medicare UPIN