Provider Demographics
NPI:1770649378
Name:WILSON, DERIC MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DERIC
Middle Name:MICHAEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-851-1800
Mailing Address - Fax:717-851-1810
Practice Address - Street 1:1010 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-3864
Practice Address - Country:US
Practice Address - Phone:717-851-1800
Practice Address - Fax:717-851-1810
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS014303207Q00000X
PAOT014074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102915087Medicaid