Healthcare Provider Details

I. General information

NPI: 1720399710
Provider Name (Legal Business Name): RICHARD A WILSON JR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 06/24/2010
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 Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD11903
License Number StateDC

VIII. Authorized Official

Name: DR. RICHARD ALPHONSO WILSON JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 202-723-8000