Provider Demographics
NPI:1841415932
Name:ROBERT W. WILSON, D.O., P.A.
Entity Type:Organization
Organization Name:ROBERT W. WILSON, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WILCOX
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO,PA
Authorized Official - Phone:239-598-5750
Mailing Address - Street 1:2940 IMMOKALEE RD
Mailing Address - Street 2:SUITE #2
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1409
Mailing Address - Country:US
Mailing Address - Phone:239-598-5750
Mailing Address - Fax:
Practice Address - Street 1:2940 IMMOKALEE RD
Practice Address - Street 2:SUITE #2
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1409
Practice Address - Country:US
Practice Address - Phone:239-598-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S00061312080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
80906OtherBLUE CROSS BLUE SHIELD
FL202096OtherFL HEALTHY KIDS
435695OtherGREAT WEST
FLF92599Medicare UPIN