Provider Demographics
NPI:1689676264
Name:ANDERSON, ROGER D (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:ANDERSON
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:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:101 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-2924
Practice Address - Country:US
Practice Address - Phone:740-374-9990
Practice Address - Fax:740-374-9993
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35063586207P00000X
OH35.063586207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0077532001Medicaid
OH000000391651OtherANTHEM
OH2276880Medicaid
OHP00338056OtherRRMCR
OH000000391651OtherANTHEM
OH2276880Medicaid
WV0077532001Medicaid