Healthcare Provider Details

I. General information

NPI: 1629002928
Provider Name (Legal Business Name): ROBERT LEWIS WILSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 DAUPHIN ST STE 7A
MOBILE AL
36608-1775
US

IV. Provider business mailing address

PO BOX 11407 DEPT # 8094
BIRMINGHAM AL
35246-0001
US

V. Phone/Fax

Practice location:
  • Phone: 251-410-4001
  • Fax: 251-410-4002
Mailing address:
  • Phone: 251-410-4001
  • Fax: 251-410-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number23859
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD42733
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: