Provider Demographics
NPI:1992791487
Name:WILSON, ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FOUNDERS PLZ STE 400
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3240
Mailing Address - Country:US
Mailing Address - Phone:860-289-3375
Mailing Address - Fax:
Practice Address - Street 1:111 FOUNDERS PLZ STE 400
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3240
Practice Address - Country:US
Practice Address - Phone:860-289-3375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA550022085N0700X, 2085P0229X, 174400000X, 2085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3056520Medicaid
MA3056520Medicaid
MAJ06397Medicare ID - Type Unspecified