Provider Demographics
NPI:1083909246
Name:WILSON, ROBERT B (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
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 1:1025 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7354
Mailing Address - Country:US
Mailing Address - Phone:843-822-5470
Mailing Address - Fax:
Practice Address - Street 1:2005 KNIGHT LANE BLDG H
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SERVS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:619-532-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
NC2017-023942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program