Provider Demographics
NPI:1215207493
Name:HOFMEISTER, ROGER WALTER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WALTER
Last Name:HOFMEISTER
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 1:4005 IVANHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-1047
Mailing Address - Country:US
Mailing Address - Phone:573-445-4890
Mailing Address - Fax:
Practice Address - Street 1:4005 IVANHOE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-1047
Practice Address - Country:US
Practice Address - Phone:573-445-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004001949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine