Provider Demographics
NPI:1982698155
Name:WILSON, ROBERT JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOSEPH
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 1:1855 TANNER WAY
Mailing Address - Street 2:
Mailing Address - City:HARRIMAN
Mailing Address - State:TN
Mailing Address - Zip Code:37748-8302
Mailing Address - Country:US
Mailing Address - Phone:865-376-6272
Mailing Address - Fax:865-376-0341
Practice Address - Street 1:1855 TANNER WAY
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8302
Practice Address - Country:US
Practice Address - Phone:865-376-6272
Practice Address - Fax:865-376-0341
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3835683Medicaid
TNQ066116Medicaid
TN3835683OtherRAILROAD MEDICARE
TN3835683Medicare ID - Type Unspecified
TN3835683Medicare PIN