Provider Demographics
NPI:1083949531
Name:ROXAS, MARIO E (ND)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:E
Last Name:ROXAS
Suffix:
Gender:M
Credentials:ND
Other - Prefix:DR
Other - First Name:MARION
Other - Middle Name:E
Other - Last Name:ROXAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ND
Mailing Address - Street 1:1501 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8280
Mailing Address - Country:US
Mailing Address - Phone:208-946-0984
Mailing Address - Fax:208-246-4995
Practice Address - Street 1:476864 HIGHWAY 95
Practice Address - Street 2:SUITE #3
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5000
Practice Address - Country:US
Practice Address - Phone:208-946-0984
Practice Address - Fax:208-246-4995
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0982175F00000X
WANT00001638175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath