Healthcare Provider Details

I. General information

NPI: 1689667917
Provider Name (Legal Business Name): WILSON COUDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S JOYCE ST SUITE 126
ARLINGTON VA
22202-1872
US

IV. Provider business mailing address

1400 S JOYCE ST SUITE 126
ARLINGTON VA
22202-1872
US

V. Phone/Fax

Practice location:
  • Phone: 703-521-6662
  • Fax: 703-521-5991
Mailing address:
  • Phone: 703-521-6662
  • Fax: 703-521-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101020537
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: