Healthcare Provider Details

I. General information

NPI: 1154309698
Provider Name (Legal Business Name): ROBERT H WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE SUITE 6600
ALBUQUERQUE NM
87106-4917
US

IV. Provider business mailing address

201 CEDAR ST SE SUITE 6600
ALBUQUERQUE NM
87106-4917
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax: 505-724-4384
Mailing address:
  • Phone: 505-724-4300
  • Fax: 505-724-4384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number92-377
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: