Provider Demographics
NPI:1699782557
Name:WILSON, ROBERT ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ALAN
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:PO BOX 30459
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-0008
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:21 W ROBY DR
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061-6113
Practice Address - Country:US
Practice Address - Phone:931-289-2450
Practice Address - Fax:931-245-0605
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD37663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886603Medicaid
TN3886603Medicare PIN
TN3886603Medicaid