Healthcare Provider Details

I. General information

NPI: 1376476341
Provider Name (Legal Business Name): RICHARD JACK WILTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2347 KERWOOD AVE APT 101
LOS ANGELES CA
90064-2646
US

IV. Provider business mailing address

2347 KERWOOD AVE APT 101
LOS ANGELES CA
90064-2646
US

V. Phone/Fax

Practice location:
  • Phone: 412-522-3656
  • Fax:
Mailing address:
  • Phone: 412-522-3656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License NumberG42945
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG42945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: