Provider Demographics
NPI:1043203227
Name:MORALES, ROGER LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEON
Last Name:MORALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-0747
Mailing Address - Country:US
Mailing Address - Phone:770-267-4992
Mailing Address - Fax:770-267-5710
Practice Address - Street 1:333 ALCOVY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2180
Practice Address - Country:US
Practice Address - Phone:770-267-4992
Practice Address - Fax:770-267-5710
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA055771208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055771OtherLICENSE
NY209751OtherLICENSE
H77910Medicare UPIN