Provider Demographics
NPI:1336106111
Name:AMISOLA, ROGELIO VIRGILIO B (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGELIO
Middle Name:VIRGILIO B
Last Name:AMISOLA
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:1425 N FAIRFIELD RD.
Practice Address - Street 2:120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-4543
Practice Address - Country:US
Practice Address - Phone:937-320-8888
Practice Address - Fax:937-320-3848
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-43042080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2507246Medicaid
OHI17740Medicare UPIN
AM2507246Medicare PIN
OH2507246Medicaid