Healthcare Provider Details

I. General information

NPI: 1922554682
Provider Name (Legal Business Name): ROBERT ANDREW DOUGLAS WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE ST
NORWALK CT
06856
US

IV. Provider business mailing address

94 TRUMAN ST
NORWALK CT
06850-3553
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-2000
  • Fax:
Mailing address:
  • Phone: 667-231-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number67076
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number67076
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: