Provider Demographics
NPI:1750520847
Name:WILSON, RODNEY
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17602 DEFOREST AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVE
Mailing Address - State:OH
Mailing Address - Zip Code:44128
Mailing Address - Country:US
Mailing Address - Phone:216-921-9457
Mailing Address - Fax:216-921-0446
Practice Address - Street 1:17602 DEFOREST AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2606
Practice Address - Country:US
Practice Address - Phone:216-921-9457
Practice Address - Fax:216-921-0446
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN473663172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver