Provider Demographics
NPI:1780758094
Name:WILSON, ROBERT WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
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 1:147 OLDE POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:HMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443
Mailing Address - Country:US
Mailing Address - Phone:910-512-4434
Mailing Address - Fax:
Practice Address - Street 1:700 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1139
Practice Address - Country:US
Practice Address - Phone:954-522-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC316962084P0800X
FLME1134772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC88423OtherBCBS
FL006432000Medicaid
NC8988423Medicaid
FLGH560ZMedicare UPIN
NC88423OtherBCBS
NC88423OtherBCBS