Healthcare Provider Details

I. General information

NPI: 1760437321
Provider Name (Legal Business Name): MICHAEL WESSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 06/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2726
US

IV. Provider business mailing address

1244 LINCOLN AVE
POMPTON LAKES NJ
07442-1420
US

V. Phone/Fax

Practice location:
  • Phone: 201-634-5403
  • Fax: 201-252-8472
Mailing address:
  • Phone: 862-666-9200
  • Fax: 862-666-9204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25MA05805500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number1640601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: