1336343631 NPI number — RICHARD DUKE WHEELER PT

Table of content: RICHARD DUKE WHEELER PT (NPI 1336343631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336343631 NPI number — RICHARD DUKE WHEELER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHEELER
Provider First Name:
RICHARD
Provider Middle Name:
DUKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHEELER
Provider Other First Name:
R
Provider Other Middle Name:
CLIFFORD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336343631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2360 EDGEHILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTAWA HILLS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-2320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-350-9640
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3949 SUNFOREST CT
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43623-4473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-474-3399
Provider Business Practice Location Address Fax Number:
419-474-5165
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1921 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2208864 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000217664 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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