Provider Demographics
NPI:1871644112
Name:WILSON, ROBERT DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 PHELAN BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6168
Mailing Address - Country:US
Mailing Address - Phone:409-866-8661
Mailing Address - Fax:409-866-4371
Practice Address - Street 1:7060 PHELAN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6168
Practice Address - Country:US
Practice Address - Phone:409-866-8661
Practice Address - Fax:409-866-4371
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4621111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4621OtherSTATE LICENSE
TX8K7170OtherBLUE CROSS BLUE SHIELD ID
TX603942Medicare ID - Type Unspecified
TXT79333Medicare UPIN