Healthcare Provider Details

I. General information

NPI: 1205362407
Provider Name (Legal Business Name): ROBERT D. WILCOX, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 W PLANO PKWY
PLANO TX
75093-4821
US

IV. Provider business mailing address

5316 W PLANO PKWY
PLANO TX
75093-4821
US

V. Phone/Fax

Practice location:
  • Phone: 972-620-1700
  • Fax: 972-248-2333
Mailing address:
  • Phone: 972-620-1700
  • Fax: 972-248-2333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number007155
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number007155
License Number StateTX

VIII. Authorized Official

Name: SHAWNA BOUDREAUX
Title or Position: FACILITY CONSULTANT
Credential:
Phone: 469-422-0641