Healthcare Provider Details

I. General information

NPI: 1275184350
Provider Name (Legal Business Name): WILTON VASCULAR MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 DANBURY RD STE 220
WILTON CT
06897-2523
US

IV. Provider business mailing address

2001 BUTTERFIELD RD STE 300
DOWNERS GROVE IL
60515-1069
US

V. Phone/Fax

Practice location:
  • Phone: 203-762-2800
  • Fax: 203-796-2810
Mailing address:
  • Phone: 630-725-2700
  • Fax: 833-842-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: LORENA ESPARZA
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 630-725-2764