Provider Demographics
NPI:1720399710
Name:RICHARD A WILSON JR MD PC
Entity Type:Organization
Organization Name:RICHARD A WILSON JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALPHONSO
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:202-723-8000
Mailing Address - Street 1:106 IRVING ST NW
Mailing Address - Street 2:SUITE 315
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2927
Mailing Address - Country:US
Mailing Address - Phone:202-723-8000
Mailing Address - Fax:202-882-7333
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:SUITE 315
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2927
Practice Address - Country:US
Practice Address - Phone:202-723-8000
Practice Address - Fax:202-882-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD11903261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC010017400Medicaid
DC010017400Medicaid
DC413915Medicare PIN