Provider Demographics
NPI:1245325794
Name:WILSON, ROGER M (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:18 BRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:BAR HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04609
Mailing Address - Country:US
Mailing Address - Phone:207-288-5082
Mailing Address - Fax:207-288-7024
Practice Address - Street 1:DOROTHEA DIX AGENCY
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-944-0733
Practice Address - Fax:207-288-3151
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD72542084P0800X
ME0072542084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010211483Medicaid
MEC66735Medicare UPIN