Healthcare Provider Details

I. General information

NPI: 1245325794
Provider Name (Legal Business Name): ROGER M WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DOROTHEA DIX AGENCY
BANGOR ME
04401
US

IV. Provider business mailing address

18 BRIDGE STREET
BAR HARBOR ME
04609
US

V. Phone/Fax

Practice location:
  • Phone: 207-944-0733
  • Fax: 207-288-3151
Mailing address:
  • Phone: 207-288-5082
  • Fax: 207-288-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD7254
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number007254
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: