Provider Demographics
NPI:1427064385
Name:WILSON, ROGER W (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
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 1:282 WAKEFIELD DR E
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-8801
Mailing Address - Country:US
Mailing Address - Phone:317-881-0507
Mailing Address - Fax:
Practice Address - Street 1:1551 E STOP 12 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1006
Practice Address - Country:US
Practice Address - Phone:317-883-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003054A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3054OtherEYEMED VISION NO.
IN3054OtherEYEMED VISION NO.