Provider Demographics
NPI:1316943806
Name:WILSON, PETER B (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-2253
Mailing Address - Country:US
Mailing Address - Phone:978-534-3179
Mailing Address - Fax:978-840-3161
Practice Address - Street 1:100 HOSPITAL RD
Practice Address - Street 2:SUITE 3B
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2253
Practice Address - Country:US
Practice Address - Phone:978-534-3179
Practice Address - Fax:978-840-3161
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2013-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA59208207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3056783Medicaid
A60951Medicare UPIN
MAJ09177Medicare ID - Type Unspecified