Provider Demographics
NPI:1922362888
Name:WILSON, ROBERT TRAVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TRAVIS
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 1:517 KERRI COVE CT APT 104
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6873
Mailing Address - Country:US
Mailing Address - Phone:804-397-9483
Mailing Address - Fax:
Practice Address - Street 1:517 KERRI COVE CT APT 104
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-6873
Practice Address - Country:US
Practice Address - Phone:804-397-9483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101257846207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine