Provider Demographics
NPI:1518922046
Name:ALDERSON, ROGER WILLIS (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WILLIS
Last Name:ALDERSON
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 1:26 MATTHEWS LN
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-2575
Mailing Address - Country:US
Mailing Address - Phone:501-394-9979
Mailing Address - Fax:
Practice Address - Street 1:26 MATTHEWS LN
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-2575
Practice Address - Country:US
Practice Address - Phone:501-394-9979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7239174400000X, 2086S0122X
OK30336207Q00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142651002Medicaid
ARF76419Medicare UPIN
AR5J351Medicare ID - Type UnspecifiedMEDICARE