Healthcare Provider Details

I. General information

NPI: 1780876797
Provider Name (Legal Business Name): TODD MATTHEW WILSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 MEDICAL CENTER DR
ROCKVILLE MD
20850-6380
US

IV. Provider business mailing address

9605 MEDICAL CENTER DR
ROCKVILLE MD
20850-6380
US

V. Phone/Fax

Practice location:
  • Phone: 800-772-6436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH0061563
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberH0061563
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: