Provider Demographics
NPI:1790767234
Name:WHEELER, GARY E (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:E
Last Name:WHEELER
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:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0414
Mailing Address - Country:US
Mailing Address - Phone:541-440-6322
Mailing Address - Fax:541-440-6399
Practice Address - Street 1:1813 WEST HARVARD AVE
Practice Address - Street 2:STE 423
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8712
Practice Address - Country:US
Practice Address - Phone:541-440-6322
Practice Address - Fax:541-440-6399
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14004207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291963Medicaid
OR291963Medicaid
ORR011WFBPGGMedicare PIN