Provider Demographics
NPI:1063412039
Name:SLAUNWHITE, WILSON ROY (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:ROY
Last Name:SLAUNWHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 COUNTY ROUTE 47
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5405
Mailing Address - Country:US
Mailing Address - Phone:518-891-2688
Mailing Address - Fax:518-891-4120
Practice Address - Street 1:309 COUNTY ROUTE 47
Practice Address - Street 2:SUITE 1
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5405
Practice Address - Country:US
Practice Address - Phone:518-891-2688
Practice Address - Fax:518-891-4120
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120898207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1063412039OtherFIDELIS
NYDD2643OtherPALMETTO GBA
NY00459458Medicaid
NY50E111OtherBLUE CROSS BLUE SHIELD
NY000401496001OtherBLUE SHIELD NENY
NYP00000040501OtherGHI FHP
NY000401496001OtherBLUE SHIELD NENY
NY1063412039OtherFIDELIS