Healthcare Provider Details

I. General information

NPI: 1962486654
Provider Name (Legal Business Name): ROBERT ALLAN WILLSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S ORLANDO AVE SUITE 300
MAITLAND FL
32751-5660
US

IV. Provider business mailing address

600 S ORLANDO AVE SUITE 300
MAITLAND FL
32751-5660
US

V. Phone/Fax

Practice location:
  • Phone: 407-647-2020
  • Fax: 407-628-1216
Mailing address:
  • Phone: 407-647-2020
  • Fax: 407-628-1216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: