Provider Demographics
NPI:1982627188
Name:WILCON, RICHARD JAY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAY
Last Name:WILCON
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 1:122 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:860-564-4062
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:860-564-4062
Practice Address - Fax:860-564-4879
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001322601Medicaid
01032260OtherCIGNA HEALTH PLANS
110093870OtherRAILROAD MEDICARE
P367719OtherOXFORD HEALTH PLANS
705139OtherCONNECTICARE
010032260CT01OtherANTHEM BC/BS
030486OtherHEALTH NET
CT001322601Medicaid
705139OtherCONNECTICARE
110005287Medicare PIN