Provider Demographics
NPI:1346203411
Name:COLLICOTT, ROGER C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:COLLICOTT
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 1:100 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1414
Mailing Address - Country:US
Mailing Address - Phone:317-718-0970
Mailing Address - Fax:317-718-0973
Practice Address - Street 1:100 MEADOW DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1414
Practice Address - Country:US
Practice Address - Phone:317-718-0970
Practice Address - Fax:317-718-0973
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033269A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100134020AMedicaid
IN197090Medicare ID - Type Unspecified
IN100134020AMedicaid