Provider Demographics
NPI:1134115728
Name:DE LA TORRE, ROGER ANIBAL (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:ANIBAL
Last Name:DE LA TORRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 W 119TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-3721
Mailing Address - Country:US
Mailing Address - Phone:913-345-6960
Mailing Address - Fax:913-345-6966
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-5619
Practice Address - Fax:573-884-4611
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3P10208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203050802Medicaid
MO203050803Medicaid
MOE98137Medicare UPIN
MO001012704Medicare ID - Type Unspecified
MO203050803Medicaid
MO923335236Medicare PIN