Provider Demographics
NPI:1831278878
Name:WILSON, ISABELLE PONGE (MD)
Entity type:Individual
Prefix:DR
First Name:ISABELLE
Middle Name:PONGE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3075
Mailing Address - Country:US
Mailing Address - Phone:212-679-4134
Mailing Address - Fax:212-679-7079
Practice Address - Street 1:50 PARK AVE # 1H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3075
Practice Address - Country:US
Practice Address - Phone:212-679-4134
Practice Address - Fax:212-679-7079
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198244174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG81303Medicare UPIN
NY08U721Medicare ID - Type Unspecified