Healthcare Provider Details

I. General information

NPI: 1427258078
Provider Name (Legal Business Name): FREDERICK H WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST # NP4
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK STREET, NP4
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 203-200-5864
  • Fax: 203-688-3501
Mailing address:
  • Phone: 203-200-5864
  • Fax: 203-688-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number56941
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number56941
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: