Provider Demographics
NPI:1679545776
Name:ETHINGTON, ROGER B (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:B
Last Name:ETHINGTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:480-892-8400
Mailing Address - Fax:602-508-4830
Practice Address - Street 1:371 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128-4706
Practice Address - Country:US
Practice Address - Phone:520-723-3000
Practice Address - Fax:520-723-5393
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ034273Medicaid
AZZ22403Medicare PIN
AZZ18WCGFR20Medicare PIN