Provider Demographics
NPI:1770571770
Name:WILSON, LYNN D (MD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:D
Last Name:WILSON
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 1:15 YORK ST
Mailing Address - Street 2:HUNTER BUILDING, 1ST FL
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3221
Mailing Address - Country:US
Mailing Address - Phone:203-688-4344
Mailing Address - Fax:203-737-1281
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:HUNTER BUILDING, 1ST FL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-688-4344
Practice Address - Fax:203-737-1281
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0337202085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001337204Medicaid
F78358Medicare UPIN
CT920000009Medicare ID - Type Unspecified