Provider Demographics
NPI:1003872631
Name:SMITH, ROGER MCDONNELL (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MCDONNELL
Last Name:SMITH
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 1:4125 LANDISVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18902
Mailing Address - Country:US
Mailing Address - Phone:215-348-2368
Mailing Address - Fax:215-348-8650
Practice Address - Street 1:4125 LANDISVILLE RD
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18902
Practice Address - Country:US
Practice Address - Phone:215-348-2368
Practice Address - Fax:215-348-8650
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009371E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
463825000OtherMAGELLAN
BUS089OtherOXFORD
000019026OtherHIGHMARK BLUE SHIELD
283220OtherMAMSI
4100632OtherAETNA
290870OtherMHN
058287OtherVALUE OPTIONS
290870OtherTRICARE
229465OtherCOMPSYCH
SM019026Medicare ID - Type Unspecified
229465OtherCOMPSYCH