Provider Demographics
NPI:1194082552
Name:JAMES WILSON MD PLLC
Entity type:Organization
Organization Name:JAMES WILSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-512-4166
Mailing Address - Street 1:2500 POND VW
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9750
Mailing Address - Country:US
Mailing Address - Phone:518-512-4166
Mailing Address - Fax:518-512-4170
Practice Address - Street 1:2500 POND VW
Practice Address - Street 2:SUITE 204
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9750
Practice Address - Country:US
Practice Address - Phone:518-512-4166
Practice Address - Fax:518-512-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01820915Medicaid
NY207773OtherNYS LICENSE