Healthcare Provider Details

I. General information

NPI: 1316045032
Provider Name (Legal Business Name): ROGER W WETSELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HALLOCK AVE
PORT JEFFERSON STATION NY
11776-1227
US

IV. Provider business mailing address

2 DATE CT
MOUNT SINAI NY
11766-1804
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-1070
  • Fax: 631-331-1126
Mailing address:
  • Phone: 631-928-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number002266
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number2634
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: