Provider Demographics
NPI:1851372775
Name:WILSON, ROGER W (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PARK PL
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4456
Mailing Address - Country:US
Mailing Address - Phone:440-247-5383
Mailing Address - Fax:440-338-1839
Practice Address - Street 1:200 PARK PL
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4456
Practice Address - Country:US
Practice Address - Phone:440-247-5383
Practice Address - Fax:440-338-1839
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1341111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH421248625003OtherMEDICAL MUTUAL OF OH
OH000000149032OtherANTHEM BC & BS
OH1052235OtherAETNA
OH44-00336OtherUNITEDHEALTH CARE
OH0629241Medicare ID - Type Unspecified
OH421248625003OtherMEDICAL MUTUAL OF OH