Provider Demographics
NPI:1346324415
Name:KIRCHNER, ROGER W (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:KIRCHNER
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 1:3715 AUTUMN GLEN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0994
Mailing Address - Country:US
Mailing Address - Phone:707-494-4107
Mailing Address - Fax:
Practice Address - Street 1:3715 AUTUMN GLEN CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0994
Practice Address - Country:US
Practice Address - Phone:707-494-4107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49078208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G490780Medicaid
CA00G490780Medicaid
00G490780Medicare ID - Type Unspecified