Provider Demographics
NPI:1689745846
Name:WILSON, DESIREE (DC)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:FOGLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1140 ROUTE 130 SOUTH
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691
Mailing Address - Country:US
Mailing Address - Phone:609-540-1267
Mailing Address - Fax:609-208-2176
Practice Address - Street 1:1140 ROUTE 130 SOUTH
Practice Address - Street 2:SUITE 2
Practice Address - City:ROBBINSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08691
Practice Address - Country:US
Practice Address - Phone:609-540-1267
Practice Address - Fax:609-208-2176
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00548700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
031813NMCMedicare PIN