Provider Demographics
NPI:1831161850
Name:WILSON, JUSTIN B (MD FACP)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 WAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-1625
Mailing Address - Country:US
Mailing Address - Phone:973-538-1800
Mailing Address - Fax:973-889-8486
Practice Address - Street 1:59 KOCH AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-4400
Practice Address - Country:US
Practice Address - Phone:973-538-1800
Practice Address - Fax:973-889-8486
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA062314207R00000X
NY204521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6567207Medicaid
NJ776501-B1JOtherMEDICARE BILLING NUMBER
NJ776501-B1JOtherMEDICARE BILLING NUMBER