Provider Demographics
NPI:1073554408
Name:ROETKER, ANNA (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ROETKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1323 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-6714
Mailing Address - Country:US
Mailing Address - Phone:937-586-9733
Mailing Address - Fax:937-586-9736
Practice Address - Street 1:1323 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-6714
Practice Address - Country:US
Practice Address - Phone:937-586-9733
Practice Address - Fax:937-586-9736
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38933207R00000X
OH35.084249207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64085798Medicaid
OH2519064Medicaid
KYP00823721OtherRAILROAD MEDICARE
KYP00148383OtherRAILROAD MEDICARE
KY0387548Medicare PIN
KYI08419Medicare UPIN
KY64085798Medicaid
KY008580090Medicare PIN