Provider Demographics
NPI:1497252118
Name:WILSON, TOMMY JOHN (MD-PHD)
Entity Type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:JOHN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1945 EASTCHESTER RD APT 20H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2111
Mailing Address - Country:US
Mailing Address - Phone:917-562-9972
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:INTERNAL MEDICINE RESIDENCY OFFICE, FLOOR 6, CENTER 12
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD965642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry