Provider Demographics
NPI:1093979874
Name:ALLYN, ROGER MARVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:MARVIN
Last Name:ALLYN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:NM
Mailing Address - Zip Code:87418-0269
Mailing Address - Country:US
Mailing Address - Phone:505-325-2472
Mailing Address - Fax:
Practice Address - Street 1:1170 HWY 170
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:NM
Practice Address - Zip Code:87418-0269
Practice Address - Country:US
Practice Address - Phone:505-325-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2219 OP152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist