Provider Demographics
NPI:1104890128
Name:WILSON, KEVIN DAVID
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DAVID
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 1:6480 HARRISON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:513-354-7651
Practice Address - Street 1:2835 MIAMI VILLAGE DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-4587
Practice Address - Country:US
Practice Address - Phone:937-449-0796
Practice Address - Fax:937-262-7468
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9416961OtherPHCS
OH2638622Medicaid
OHP00421513OtherMEDICARE RAILROAD
OH000000385602OtherANTHEM
OH2638622Medicaid
OHWI4178041Medicare PIN