Provider Demographics
NPI:1063465110
Name:ADLER, ROGER TODD (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:TODD
Last Name:ADLER
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 1:725 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-5073
Mailing Address - Country:US
Mailing Address - Phone:309-353-6660
Mailing Address - Fax:309-353-7664
Practice Address - Street 1:725 S 14TH ST
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-5073
Practice Address - Country:US
Practice Address - Phone:309-353-6660
Practice Address - Fax:309-353-7664
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-107471207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H13693Medicare UPIN
OH4178562Medicare ID - Type Unspecified