Provider Demographics
NPI:1245216068
Name:WILSON, ROBERT S (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAGLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19403-1829
Mailing Address - Country:US
Mailing Address - Phone:610-539-6000
Mailing Address - Fax:610-539-9314
Practice Address - Street 1:100 EAGLEVILLE RD
Practice Address - Street 2:
Practice Address - City:EAGLEVILLE
Practice Address - State:PA
Practice Address - Zip Code:19403-1829
Practice Address - Country:US
Practice Address - Phone:610-539-6000
Practice Address - Fax:610-539-9314
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-004237-L208D00000X, 207QA0401X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Not Answered207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA136659FBDMedicare ID - Type UnspecifiedMEDICARE
PAC23646Medicare UPIN