Provider Demographics
NPI:1417981333
Name:GUILLEMETTE, ROGER R (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:R
Last Name:GUILLEMETTE
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 1:3009 N BALLAS RD STE 387C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2324
Mailing Address - Country:US
Mailing Address - Phone:314-996-5900
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD STE 387C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2324
Practice Address - Country:US
Practice Address - Phone:314-996-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108658207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F92911Medicare UPIN
MO004012313Medicare PIN
MO991373002Medicare PIN