Provider Demographics
NPI:1649575937
Name:WILSON, ROBERT GEORGE (IDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GEORGE
Last Name:WILSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 TESSENTEE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NC
Mailing Address - Zip Code:28734
Mailing Address - Country:US
Mailing Address - Phone:619-630-3020
Mailing Address - Fax:
Practice Address - Street 1:515 TESSENTEE RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:NC
Practice Address - Zip Code:28734
Practice Address - Country:US
Practice Address - Phone:619-630-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman