Provider Demographics
NPI:1073662383
Name:JENSEN, ROGER DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DAVID
Last Name:JENSEN
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 1:70 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-8463
Mailing Address - Country:US
Mailing Address - Phone:828-645-5531
Mailing Address - Fax:
Practice Address - Street 1:300 ENOLA RD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4608
Practice Address - Country:US
Practice Address - Phone:828-438-6558
Practice Address - Fax:828-438-6560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC84726Medicare UPIN