1033249800 NPI number — ROBERT H WILSON M.D.

Table of content: ROBERT H WILSON M.D. (NPI 1033249800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033249800 NPI number — ROBERT H WILSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
ROBERT
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033249800
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
632 BROADWAY PH 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10012-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-294-3414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CANAAN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06840-5408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-663-6331
Provider Business Practice Location Address Fax Number:
415-252-7176
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  76440 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 256959 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16639243 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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