Provider Demographics
NPI:1710907662
Name:WILEY, ROGER P JR (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:P
Last Name:WILEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22100 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8431
Mailing Address - Country:US
Mailing Address - Phone:208-416-2932
Mailing Address - Fax:
Practice Address - Street 1:336 WHITING LN
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-4451
Practice Address - Country:US
Practice Address - Phone:208-416-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010354622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1710907662Medicaid
VA007244037Medicaid
WV0123539000Medicaid
WV0123539000Medicaid
D94281Medicare UPIN
VA015803C19Medicare PIN