Basic Information
| Provider Information | |||||||||
| NPI: | 1770757692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILT | ||||||||
| FirstName: | RAY | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 23 PLUMER RD UNIT 23 | ||||||||
| Address2: | UNIT 12 | ||||||||
| City: | EPPING | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030421713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037342567 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 426 CALEF HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036649003 | ||||||||
| FaxNumber: | 6036640133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15010 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS014529 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.