Provider Demographics
NPI:1114115003
Name:RICHARD J. WILCON
Entity Type:Organization
Organization Name:RICHARD J. WILCON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:WILCON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-564-4068
Mailing Address - Street 1:122 PLAINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MOOSUP
Mailing Address - State:CT
Mailing Address - Zip Code:06354-1632
Mailing Address - Country:US
Mailing Address - Phone:860-564-4068
Mailing Address - Fax:860-564-4879
Practice Address - Street 1:122 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:MOOSUP
Practice Address - State:CT
Practice Address - Zip Code:06354-1632
Practice Address - Country:US
Practice Address - Phone:860-564-4068
Practice Address - Fax:860-564-4879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C01833Medicare PIN
F25158Medicare UPIN