Provider Demographics
NPI:1932916525
Name:WILSON, ROGER DEAN
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DEAN
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 1:436 S 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-1981
Mailing Address - Country:US
Mailing Address - Phone:714-786-5227
Mailing Address - Fax:
Practice Address - Street 1:436 S 7TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-1981
Practice Address - Country:US
Practice Address - Phone:714-786-5227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist