Healthcare Provider Details

I. General information

NPI: 1508854274
Provider Name (Legal Business Name): ROBERT E. WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 S CEDAR CREST BLVD SUITE #307
ALLENTOWN PA
18103-6218
US

IV. Provider business mailing address

1245 S CEDAR CREST BLVD SUITE #301
ALLENTOWN PA
18103-6258
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-1757
  • Fax: 610-402-9089
Mailing address:
  • Phone: 610-402-1757
  • Fax: 610-402-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS007250L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: