Provider Demographics
NPI:1316023492
Name:KATHOL, ROGER GERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GERALD
Last Name:KATHOL
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 1:3004 FOXPOINT RD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1072
Mailing Address - Country:US
Mailing Address - Phone:952-426-1626
Mailing Address - Fax:
Practice Address - Street 1:3004 FOXPOINT RD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1072
Practice Address - Country:US
Practice Address - Phone:952-426-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2015-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44448207R00000X
IA20592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA01600Medicare UPIN