Healthcare Provider Details

I. General information

NPI: 1386757482
Provider Name (Legal Business Name): ROBERT WHITING WILSON JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 TOWN CENTER DR STE 218
RESTON VA
20190-3215
US

IV. Provider business mailing address

1800 TOWN CENTER DR STE 218
RESTON VA
20190-3238
US

V. Phone/Fax

Practice location:
  • Phone: 703-437-8324
  • Fax: 703-709-0675
Mailing address:
  • Phone: 703-437-8324
  • Fax: 703-536-7407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0101032806
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD039356
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: