Provider Demographics
NPI:1588764278
Name:ROESE, WILBUR RAY (MD)
Entity type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:RAY
Last Name:ROESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4701 FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4619
Mailing Address - Country:US
Mailing Address - Phone:410-661-7676
Mailing Address - Fax:410-661-3266
Practice Address - Street 1:4701 FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4619
Practice Address - Country:US
Practice Address - Phone:410-661-7676
Practice Address - Fax:410-661-3266
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045789207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4105338 00Medicaid