Basic Information
| Provider Information | |||||||||
| NPI: | 1831161850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. FACP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 527 WAKEFIELD DR | ||||||||
| Address2: | |||||||||
| City: | METUCHEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735381800 | ||||||||
| FaxNumber: | 9738898486 | ||||||||
| Practice Location | |||||||||
| Address1: | 59 KOCH AVE | ||||||||
| Address2: | |||||||||
| City: | MORRIS PLAINS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079504400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735381800 | ||||||||
| FaxNumber: | 9738898486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA062314 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 204521 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6567207 | 05 | NJ | MEDICAID | 776501-B1J | 01 | NJ | MEDICARE BILLING NUMBER | OTHER |