Basic Information
| Provider Information | |||||||||
| NPI: | 1184720476 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT LEE WILSON, M.D., MEDICAL CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3675 AMESBURY ROAD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236641324 | ||||||||
| FaxNumber: | 3239535119 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 ATLANTIC AVENUE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908061701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629331550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3236641324 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A23286 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.