Provider Demographics
NPI:1962478842
Name:WILSON, THOMAS WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:570-882-3007
Practice Address - Street 1:16 WOODBINE LANE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17821-8029
Practice Address - Country:US
Practice Address - Phone:570-271-6531
Practice Address - Fax:570-271-7146
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049787L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015265000003Medicaid
PAGU039847OtherPA MEDICARE GROUP
NY01736281Medicaid
NY01736281Medicaid
PAGU039847OtherPA MEDICARE GROUP