Provider Demographics
NPI:1477971885
Name:WILSON, ROBERT BORDEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BORDEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8951
Mailing Address - Fax:318-212-6752
Practice Address - Street 1:2300 HOSPITAL DR STE 120
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2193
Practice Address - Country:US
Practice Address - Phone:318-212-7982
Practice Address - Fax:318-212-7989
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2019-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA306374208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2449508Medicaid