Provider Demographics
NPI:1972233708
Name:WIBISONO, ESRAVILA ARIYA (MD)
Entity Type:Individual
Prefix:
First Name:ESRAVILA
Middle Name:ARIYA
Last Name:WIBISONO
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 1:56 FRANKLIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1281
Mailing Address - Country:US
Mailing Address - Phone:203-709-8685
Mailing Address - Fax:203-709-3518
Practice Address - Street 1:56 FRANKLIN ST STE 1
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1281
Practice Address - Country:US
Practice Address - Phone:203-709-8685
Practice Address - Fax:203-709-3518
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT06-0646844390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program