Provider Demographics
NPI:1588629505
Name:COLUCCI, WILSON S (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:S
Last Name:COLUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:732 HARRISON AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-638-7490
Practice Address - Fax:617-414-8742
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA44944207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110003480AMedicaid
MA110003480AMedicaid
MAE05533Medicare ID - Type Unspecified