Provider Demographics
NPI:1093832503
Name:ROGER, AIME KOUADIO
Entity Type:Individual
Prefix:DR
First Name:AIME
Middle Name:KOUADIO
Last Name:ROGER
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:AIME
Other - Middle Name:KOUADIO
Other - Last Name:ROGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:817 ORCHARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CROYDON
Mailing Address - State:PA
Mailing Address - Zip Code:19021
Mailing Address - Country:US
Mailing Address - Phone:215-785-3308
Mailing Address - Fax:215-785-3308
Practice Address - Street 1:817 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:CROYDON
Practice Address - State:PA
Practice Address - Zip Code:19021-6942
Practice Address - Country:US
Practice Address - Phone:215-785-3308
Practice Address - Fax:215-785-3308
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070267L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA234Medicare UPIN