Provider Demographics
NPI:1386723328
Name:WILT, JESSIE SWAIN (MD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:SWAIN
Last Name:WILT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:JESSIE
Other - Middle Name:SWAIN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-277-8674
Mailing Address - Fax:908-277-8927
Practice Address - Street 1:140 PARK AVE
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932
Practice Address - Country:US
Practice Address - Phone:973-404-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207863207RP1001X
NJ25MA09052000207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01959544Medicaid
NY49C921Medicare ID - Type Unspecified
NYG97914Medicare UPIN