Provider Demographics
NPI:1851370407
Name:WILTON, SUSAN ROTH (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ROTH
Last Name:WILTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-3844
Mailing Address - Country:US
Mailing Address - Phone:610-933-3498
Mailing Address - Fax:610-933-5052
Practice Address - Street 1:720 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3844
Practice Address - Country:US
Practice Address - Phone:610-933-3498
Practice Address - Fax:610-933-5052
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD054357L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015185260001Medicaid
PA5914840001OtherPTAN
PA5914840001Medicare NSC
PA5914840001OtherPTAN
PA0015185260001Medicaid
PA754585R3YMedicare PIN
PA754585HDQMedicare ID - Type Unspecified