Provider Demographics
NPI:1437190683
Name:WILSON, ROBIN A (DO)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 81055
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-0018
Mailing Address - Country:US
Mailing Address - Phone:864-963-9149
Mailing Address - Fax:864-967-4727
Practice Address - Street 1:205 NORTH MAPLE STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681
Practice Address - Country:US
Practice Address - Phone:864-963-9149
Practice Address - Fax:864-967-4727
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0727207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC007272Medicaid
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SC6980369OtherCIGNA ID
SC7268402OtherAETNA ID
SC576007863095OtherBCBS OF SC ID
SC576007863071OtherBLUECHOICE HEALTHPLAN ID
SC6980369OtherCIGNA ID