Provider Demographics
NPI:1518001197
Name:WILSON, STEPHEN A (MD CPMR)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD CPMR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9314 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1135
Mailing Address - Country:US
Mailing Address - Phone:718-830-2700
Mailing Address - Fax:718-830-3257
Practice Address - Street 1:9314 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1135
Practice Address - Country:US
Practice Address - Phone:718-830-2700
Practice Address - Fax:718-830-3257
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181294225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY61H121Medicare UPIN