Provider Demographics
NPI:1710931076
Name:WILSON, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:WILSON
Suffix:
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 1:1140 W LA VETA AVENUE
Mailing Address - Street 2:SUITE 860
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868
Mailing Address - Country:US
Mailing Address - Phone:714-835-6500
Mailing Address - Fax:714-541-6105
Practice Address - Street 1:1140 W LA VETA AVENUE
Practice Address - Street 2:SUITE 860
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-835-6500
Practice Address - Fax:714-541-6105
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22782207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A90777Medicare UPIN