Provider Demographics
NPI:1659361103
Name:WILSON, SCOTT NUMO (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:NUMO
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5 LONGFELLOW PL
Mailing Address - Street 2:SUITE 213
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2839
Mailing Address - Country:US
Mailing Address - Phone:617-964-7309
Mailing Address - Fax:617-742-6954
Practice Address - Street 1:5 LONGFELLOW PL
Practice Address - Street 2:SUITE 213
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2839
Practice Address - Country:US
Practice Address - Phone:617-964-7309
Practice Address - Fax:617-742-6954
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA515072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA051507OtherTUFTS
MAJ03672OtherBCBS MA
MAJ03672Medicare ID - Type Unspecified
B74482Medicare UPIN