MEDICARE: DR. MARK WILLIAM WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	208200	NY

General Provider Information

NPI Number	:	1285632794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WILLIAM WILSON MD

Provider Business Mailing Address
First Line	:	330 W 58TH ST
Second Line	:	313
City	:	NEW YORK
State	:	NY
Zip	:	10019-1827
Country	:	US
Telephone Number	:	917-441-2344
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 W 58TH ST
Second Line	:	313
City	:	NEW YORK
State	:	NY
Zip	:	10019-1827
Country	:	US
Telephone Number	:	917-441-2344
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	12/13/2013

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