Provider Demographics
NPI:1487710810
Name:WILSON, ROBERT MARSHALL JR (DO)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MARSHALL
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1731
Mailing Address - Country:US
Mailing Address - Phone:302-422-6677
Mailing Address - Fax:302-422-9705
Practice Address - Street 1:901 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1731
Practice Address - Country:US
Practice Address - Phone:302-422-6677
Practice Address - Fax:302-422-9705
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0005119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC2-0005119OtherSTATE LICENSE #
DE0001177603Medicaid
DE0001177603Medicaid
DEG58001Medicare UPIN
DE0001177603Medicaid