Provider Demographics
NPI:1679612550
Name:COLDREN, ROGER W (DC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:COLDREN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5883 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:EXPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15632-1331
Mailing Address - Country:US
Mailing Address - Phone:724-325-4042
Mailing Address - Fax:724-733-7069
Practice Address - Street 1:5883 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EXPORT
Practice Address - State:PA
Practice Address - Zip Code:15632-1331
Practice Address - Country:US
Practice Address - Phone:724-325-4042
Practice Address - Fax:724-733-7069
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-002028-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT29502Medicare UPIN