Healthcare Provider Details

I. General information

NPI: 1073586897
Provider Name (Legal Business Name): ROBERT S. WILDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

PO BOX 1063
BURLINGTON VT
05402-1063
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-0000
  • Fax:
Mailing address:
  • Phone: 802-847-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD20420
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number042-0013813
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberM8801
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: