Provider Demographics
NPI:1720136757
Name:HOSMER, WYLIE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:WYLIE
Middle Name:DAVID
Last Name:HOSMER
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 1:55 MERIDEN AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3237
Mailing Address - Country:US
Mailing Address - Phone:860-621-9316
Mailing Address - Fax:860-620-5526
Practice Address - Street 1:55 MERIDEN AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3237
Practice Address - Country:US
Practice Address - Phone:860-621-9316
Practice Address - Fax:860-620-5526
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048427207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A937780Medicaid
I72178Medicare UPIN