Provider Demographics
NPI:1518981182
Name:OWEN, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:OWEN
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:PO BOX 2003
Mailing Address - Street 2:THE PEDIATRIC NETWORK
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2003
Mailing Address - Country:US
Mailing Address - Phone:802-885-5716
Mailing Address - Fax:
Practice Address - Street 1:29 RIDGEWOOD RD
Practice Address - Street 2:THE PEDIATRIC NETWORK
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-3050
Practice Address - Country:US
Practice Address - Phone:802-885-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0005683208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0004629Medicaid
NH30009000Medicaid
VT0004629Medicaid
VTVT4629Medicare ID - Type Unspecified