Provider Demographics
NPI:1861646374
Name:WILSON, ROBERT EDWARD JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:WILSON
Suffix:JR
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 1:2411 RING RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5930
Mailing Address - Country:US
Mailing Address - Phone:270-982-5550
Mailing Address - Fax:270-982-5549
Practice Address - Street 1:2411 RING RD STE 105
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5930
Practice Address - Country:US
Practice Address - Phone:270-982-5550
Practice Address - Fax:270-982-5549
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44317207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100161520Medicaid
KYK018362Medicare PIN
KY7100161520Medicaid