Provider Demographics
NPI:1265469068
Name:WILKINSON, BRADFORD W (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:W
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-6748
Practice Address - Street 1:6 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:CT
Practice Address - Zip Code:06422
Practice Address - Country:US
Practice Address - Phone:860-349-1058
Practice Address - Fax:860-358-8652
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030907207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001309071Medicaid
CT001309071Medicaid
CT110006931Medicare PIN