Provider Demographics
NPI:1558475657
Name:WILSON, PAULETTE C (MD)
Entity Type:Individual
Prefix:
First Name:PAULETTE
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W FULLERTON AVE
Mailing Address - Street 2:2ND FLR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8160
Mailing Address - Country:US
Mailing Address - Phone:773-549-7757
Mailing Address - Fax:773-549-1221
Practice Address - Street 1:1150 W FULLERTON AVE
Practice Address - Street 2:2ND FLR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-8160
Practice Address - Country:US
Practice Address - Phone:773-549-7757
Practice Address - Fax:773-549-1221
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43900Medicare UPIN
ILL34401Medicare PIN