Provider Demographics
NPI:1134108772
Name:WEENIG, ROGER H (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:H
Last Name:WEENIG
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 1:7205 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3134
Mailing Address - Country:US
Mailing Address - Phone:763-571-4000
Mailing Address - Fax:763-571-4000
Practice Address - Street 1:7205 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:763-571-4000
Practice Address - Fax:763-571-4000
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN724483500Medicaid
MN724483500Medicaid
MN070013667Medicare ID - Type UnspecifiedRAILROAD
MN070000525Medicare ID - Type Unspecified