Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 078469 | GA |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 55724 | CT |
NPI | 1215223276 |
---|---|
Provider Name | Dr. Robert George Willson |
First Address | Farmington, CT 06030-0001 |
Second Address | Augusta, GA 30912-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2011 |
Last Update Date | 17/03/2018 |