Provider Demographics
NPI:1962486654
Name:WILLSON, ROBERT ALLAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALLAN
Last Name:WILLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S ORLANDO AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5660
Mailing Address - Country:US
Mailing Address - Phone:407-647-2020
Mailing Address - Fax:407-628-1216
Practice Address - Street 1:600 S ORLANDO AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5660
Practice Address - Country:US
Practice Address - Phone:407-647-2020
Practice Address - Fax:407-628-1216
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19256OtherBCBS
FL19256ZMedicare ID - Type Unspecified
FL19256OtherBCBS