Provider Demographics
NPI:1285730002
Name:WILSON, DEBORAH J (DO)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-4924
Mailing Address - Country:US
Mailing Address - Phone:610-791-2755
Mailing Address - Fax:
Practice Address - Street 1:1702 S 4TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-4924
Practice Address - Country:US
Practice Address - Phone:610-791-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009098L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101365386Medicaid
PA101365386Medicaid
PA0010063933Medicare ID - Type Unspecified