Provider Demographics
NPI:1003959677
Name:DOUGLAS J. ROGER M.D.,INC., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:DOUGLAS J. ROGER M.D.,INC., A PROFESSIONAL CORPORATION
Other - Org Name:ORTHOPEDIC INSTITUTE OF COACHELLA VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-416-4511
Mailing Address - Street 1:PO BOX 2110
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263-2110
Mailing Address - Country:US
Mailing Address - Phone:760-416-4511
Mailing Address - Fax:760-416-4512
Practice Address - Street 1:1180 N INDIAN CANYON DR STE W201
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4876
Practice Address - Country:US
Practice Address - Phone:760-416-4511
Practice Address - Fax:760-416-4512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77670174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF22816Medicare UPIN
CAZZZ23012ZMedicare PIN