Healthcare Provider Details

I. General information

NPI: 1073672275
Provider Name (Legal Business Name): GREGORY JOHN WIGHTMAN L.P.C.C. SUPV.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WAYNE AVE BUILDING #66
DAYTON OH
45420-1833
US

IV. Provider business mailing address

30 E BROAD ST 11TH FLOOR
COLUMBUS OH
43215-3414
US

V. Phone/Fax

Practice location:
  • Phone: 937-258-0440
  • Fax: 937-258-6235
Mailing address:
  • Phone: 614-466-6583
  • Fax: 614-995-3268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE0000394 SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: