Provider Demographics
NPI:1871599944
Name:WOLCOTT, ROGER JAMES (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JAMES
Last Name:WOLCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5902 66TH ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5933
Mailing Address - Country:US
Mailing Address - Phone:806-797-2139
Mailing Address - Fax:806-797-3105
Practice Address - Street 1:5902 66TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-3048
Practice Address - Country:US
Practice Address - Phone:806-797-2139
Practice Address - Fax:806-797-3105
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4620208100000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110687404Medicaid
TX172052601Medicaid
TX172053401Medicaid
TX172052601Medicaid
TX172053401Medicaid
TXF74790Medicare UPIN