Provider Demographics
NPI:1629189279
Name:WILSON, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
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 1:717 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3459
Mailing Address - Country:US
Mailing Address - Phone:910-363-5095
Mailing Address - Fax:910-363-5074
Practice Address - Street 1:717 N HOWE ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3459
Practice Address - Country:US
Practice Address - Phone:910-363-5075
Practice Address - Fax:910-363-5074
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC3312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC128FTOtherBCBS PROVIDER NUMBER
NC89128FTMedicaid
NC2281786CMedicare ID - Type UnspecifiedPROVIDER NUMBER