Healthcare Provider Details

I. General information

NPI: 1255486221
Provider Name (Legal Business Name): RICHARD ALPHONSO WILSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 IRVING ST NW SUITE 315
WASHINGTON DC
20010-2927
US

IV. Provider business mailing address

106 IRVING ST NW SUITE 315
WASHINGTON DC
20010-2927
US

V. Phone/Fax

Practice location:
  • Phone: 202-723-8000
  • Fax: 202-882-7333
Mailing address:
  • Phone: 202-723-8000
  • Fax: 202-882-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD11903
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberD0043663
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: