Healthcare Provider Details

I. General information

NPI: 1477971885
Provider Name (Legal Business Name): ROBERT BORDEN WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 HOSPITAL DR STE 120
BOSSIER CITY LA
71111-2193
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-7982
  • Fax: 318-212-7989
Mailing address:
  • Phone: 318-212-8951
  • Fax: 318-212-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number306374
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: