Provider Demographics
NPI:1609868942
Name:WILSON, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
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 1:111 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2010
Mailing Address - Country:US
Mailing Address - Phone:717-231-8772
Mailing Address - Fax:717-231-8435
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101
Practice Address - Country:US
Practice Address - Phone:717-231-8772
Practice Address - Fax:717-231-8435
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038133207R00000X
FLME104749207R00000X
PAMD051413L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0006565876GMedicaid
GA1189235OtherFIRST HEALTH
PA103115186Medicaid
GA110235293OtherRAILROAD MEDICARE
FL914260600Medicaid
GA52484977OtherBCBS GA
GA0006565876GMedicaid
FL914260600Medicaid