Provider Demographics
NPI:1770560096
Name:KO, WILSON (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:KO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13625 MAPLE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3870
Mailing Address - Country:US
Mailing Address - Phone:718-358-5900
Mailing Address - Fax:718-463-8049
Practice Address - Street 1:13625 MAPLE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3870
Practice Address - Country:US
Practice Address - Phone:718-358-5900
Practice Address - Fax:718-463-8049
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY158635207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY160517OtherELDER PLAN
NY20E801OtherBLUE CROSS AND BLUE SHILED
NY01067050Medicaid
NYNS2922OtherOXFORD
NY01067050Medicaid