MEDICARE: ROBERT L WILSON M D INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	A23286	CA

General Provider Information

NPI Number	:	1346474889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT L WILSON M D INC

Provider Business Mailing Address
First Line	:	2815 W SUNSET BLVD
Second Line	:	205
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-2167
Country	:	US
Telephone Number	:	213-484-1271
Fax Number	:	213-484-1217

Provider Business Practice Location Address
First Line	:	2815 W SUNSET BLVD
Second Line	:	205
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-2167
Country	:	US
Telephone Number	:	213-484-1271
Fax Number	:	213-484-1217

Authorized Official
Title or Position	:	CEO/ PRESIDENT
Name	:	DR. ROBERT L WILSON
Credential	:	M.D.
Telephone Number	:	213-484-1271

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	05/12/2009

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