Provider Demographics
NPI:1356313324
Name:BALDOZA, ROGER LOTA (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LOTA
Last Name:BALDOZA
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 1:511 SOUTH ABBE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6301
Mailing Address - Country:US
Mailing Address - Phone:440-366-6640
Mailing Address - Fax:440-366-5130
Practice Address - Street 1:511 SOUTH ABBE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6301
Practice Address - Country:US
Practice Address - Phone:440-366-6640
Practice Address - Fax:440-366-5130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH100340OtherKAISER
OH000000127876OtherANTHEM
53158OtherQUAL CHOICE
OH0169919Medicaid
OH04931010OtherBCBS
53158OtherQUAL CHOICE
OH0169919Medicaid