Provider Demographics
NPI:1174521322
Name:WILSON, JUNE-ANN NICOLE (MD)
Entity type:Individual
Prefix:
First Name:JUNE-ANN
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0010
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:546 EASTERN PARKWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-1604
Practice Address - Country:US
Practice Address - Phone:718-604-4800
Practice Address - Fax:718-604-4828
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053736207R00000X
NY327186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA615580961AMedicaid
GA11SCCPWMedicare PIN