Provider Demographics
NPI:1518900984
Name:WILSON JR, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WILSON JR
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 1:513 N SHILOH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-3343
Mailing Address - Country:US
Mailing Address - Phone:479-419-9902
Mailing Address - Fax:479-419-9950
Practice Address - Street 1:513 N SHILOH ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-3343
Practice Address - Country:US
Practice Address - Phone:479-419-9902
Practice Address - Fax:479-419-9950
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103290001Medicaid
AR55767Medicare PIN
ARD75067Medicare UPIN