Provider Demographics
NPI:1851475297
Name:WILSON, ROGER LEWIS (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LEWIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7721 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1211
Mailing Address - Country:US
Mailing Address - Phone:614-861-0950
Mailing Address - Fax:614-861-5665
Practice Address - Street 1:7721 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-1211
Practice Address - Country:US
Practice Address - Phone:614-861-0950
Practice Address - Fax:614-861-5665
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3318152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2200501OtherUNITED HEALTH CARE
OH000000119534OtherANTHEM PROVIDER ID
OH142757OtherEYEMED ID
OH2200501OtherUNITED HEALTH CARE
OHT47059Medicare UPIN