Healthcare Provider Details

I. General information

NPI: 1922489269
Provider Name (Legal Business Name): MICHAEL PAUL WILSON JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 07/13/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-7575
  • Fax: 845-333-7202
Mailing address:
  • Phone: 845-333-7575
  • Fax: 845-333-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number302827
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: