Provider Demographics
NPI:1053359976
Name:AVILES, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:AVILES
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 1:4008 GRIMES AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5060
Mailing Address - Country:US
Mailing Address - Phone:612-308-2319
Mailing Address - Fax:
Practice Address - Street 1:3955 PARKLAWN AVE
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5655
Practice Address - Country:US
Practice Address - Phone:953-831-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44640208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426217Medicaid
OH2426217Medicaid