Provider Demographics
NPI:1477596153
Name:ROARK, ROGER LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEE
Last Name:ROARK
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 1:555 KITCHINGS DR STE C
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3576
Mailing Address - Country:US
Mailing Address - Phone:704-873-2516
Mailing Address - Fax:
Practice Address - Street 1:555 KITCHINGS DR STE C
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-3576
Practice Address - Country:US
Practice Address - Phone:704-873-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20190208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC71981OtherBCBS
NC79 71981Medicaid
C81182Medicare UPIN