Provider Demographics
NPI:1629189279
Name:WILSON, ROBERT ALLEN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
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 1:328 NE 48TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-5305
Mailing Address - Country:US
Mailing Address - Phone:919-593-3402
Mailing Address - Fax:
Practice Address - Street 1:120 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-5002
Practice Address - Country:US
Practice Address - Phone:910-592-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC3312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC128FTOtherBCBS PROVIDER NUMBER
NC89128FTMedicaid
NC2281786CMedicare ID - Type UnspecifiedPROVIDER NUMBER