Provider Demographics
NPI:1063639045
Name:FOX, ROGER EVAN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:EVAN
Last Name:FOX
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 1:1375 CAMINO REAL STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2764
Mailing Address - Country:US
Mailing Address - Phone:909-884-1500
Mailing Address - Fax:909-383-0025
Practice Address - Street 1:1375 CAMINO REAL STE 130
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2764
Practice Address - Country:US
Practice Address - Phone:909-884-1500
Practice Address - Fax:909-383-0025
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA463252083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine