Provider Demographics
NPI:1265441638
Name:WILSON, ROBERT D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
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 1:10379 SE CRESCENT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97086-9100
Mailing Address - Country:US
Mailing Address - Phone:503-777-6306
Mailing Address - Fax:
Practice Address - Street 1:10379 SE CRESCENT RIDGE DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97086-9100
Practice Address - Country:US
Practice Address - Phone:503-777-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10867207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR050036209OtherRR MEDICARE
WA1374701Medicaid
OR050036209OtherRR MEDICARE
OR00WCJPPU3Medicare ID - Type Unspecified
OR216283Medicare ID - Type Unspecified