Active NPI
Robert Wayne Wilson, MD
- Psychiatry Physician
- Fort Lauderdale, FL
National Provider Identifier
1780758094
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- ME113477
- Practice address
- 700 SE 3Rd Ave
Fort Lauderdale, FL 33316-1139 - Phone
- (954) 522-3132
- NPI assigned
- Nov 20, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 31696 | NC | |
| Psychiatry Physician | 2084P0800X | ME113477 | FL | Primary |
Addresses
Primary practice location
700 SE 3Rd Ave
Fort Lauderdale, FL 33316-1139
Mailing address
147 Olde Point Road
Hmpstead, NC 28443
Phone (910) 512-4434
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 88423 | Other | NC | BCBS |
| 006432000 | Medicaid | FL | |
| 8988423 | Medicaid | NC |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ME113477 | FL | MD | Psychiatry Physician |
| 31696 | NC | MD | Psychiatry Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Evergreen Behavioral Management Inc | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Whiteville, NC
- NPI 1790860971
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163980800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1495670400000",
"number": "1780758094",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "147 OLDE POINT ROAD",
"city": "HMPSTEAD",
"state": "NC",
"postal_code": "28443",
"telephone_number": "910-512-4434"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "700 SE 3RD AVE",
"city": "FORT LAUDERDALE",
"state": "FL",
"postal_code": "333161139",
"telephone_number": "954-522-3132"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "ROBERT",
"middle_name": "WAYNE",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-11-20",
"last_updated": "2017-05-25",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "NC",
"license": "31696",
"primary": false
},
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "FL",
"license": "ME113477",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BCBS",
"identifier": "88423",
"state": "NC"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "006432000",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "8988423",
"state": "NC"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Lauderdale, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 25, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.