Provider Demographics
NPI:1033249800
Name:WILSON, ROBERT H (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:H
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 1:632 BROADWAY PH 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2614
Mailing Address - Country:US
Mailing Address - Phone:347-294-3414
Mailing Address - Fax:
Practice Address - Street 1:632 BROADWAY PH 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2614
Practice Address - Country:US
Practice Address - Phone:347-294-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT76440207Q00000X
NY256959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16639243Medicaid
COC803490Medicare PIN