Provider Demographics
NPI:1467919001
Name:WILSON, NATHANIEL ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ROBERT
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 1:6431 FANNIN ST.
Mailing Address - Street 2:MSB 1.150
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3806
Mailing Address - Country:US
Mailing Address - Phone:618-975-0382
Mailing Address - Fax:
Practice Address - Street 1:600 S PAULINA ST STE 403
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3806
Practice Address - Country:US
Practice Address - Phone:312-942-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-01
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS8403207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program