Provider Demographics
NPI:1912978743
Name:WHEELER, WAYNE BLACKBURN (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:BLACKBURN
Last Name:WHEELER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 28TH ST
Mailing Address - Street 2:APT 621
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2641
Mailing Address - Country:US
Mailing Address - Phone:740-353-5044
Mailing Address - Fax:740-353-7904
Practice Address - Street 1:1610 28TH ST
Practice Address - Street 2:APT 621
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2641
Practice Address - Country:US
Practice Address - Phone:740-353-5044
Practice Address - Fax:740-353-7904
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35047628207P00000X, 209800000X, 207P00000X, 207P00000X
KY22486207PE0004X, 209800000X, 209800000X, 209800000X
IL036071760209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A15178Medicare UPIN