Provider Demographics
NPI:1477539740
Name:ROAN, MINDA UNIDAD (MD)
Entity Type:Individual
Prefix:DR
First Name:MINDA
Middle Name:UNIDAD
Last Name:ROAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINDA
Other - Middle Name:UNIDAD
Other - Last Name:SAGUINSIN ROAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7107
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506-1107
Mailing Address - Country:US
Mailing Address - Phone:580-574-7407
Mailing Address - Fax:
Practice Address - Street 1:110 NW 31ST ST STE 201
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6100
Practice Address - Country:US
Practice Address - Phone:580-585-5549
Practice Address - Fax:580-699-8223
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1536401Medicaid
C61527Medicare UPIN
NJ1536401Medicaid