=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346474889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT L WILSON M D INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2009
-----------------------------------------------------
Last Update Date | 05/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2815 W SUNSET BLVD 205
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-484-1271
-----------------------------------------------------
Fax | 213-484-1217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2815 W SUNSET BLVD 205
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90026-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-484-1271
-----------------------------------------------------
Fax | 213-484-1217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT L WILSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 213-484-1271
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A23286
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------