Provider Demographics
NPI:1679512792
Name:WILSON, STEPHEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:960 MASSACHUSETTS AVENUE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 MELNEA CASS BLVD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-4401
Practice Address - Country:US
Practice Address - Phone:617-414-2080
Practice Address - Fax:617-414-2090
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA283810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110167078AMedicaid
NH3127148Medicaid
PAG76785Medicare UPIN