Provider Demographics
NPI:1548207590
Name:FIFE, ROGER L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:FIFE
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 1:780 W. OLIVE AVE. SUITE 104
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2437
Mailing Address - Country:US
Mailing Address - Phone:209-723-9879
Mailing Address - Fax:209-384-9027
Practice Address - Street 1:780 W. OLIVE AVE. SUITE 104
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2437
Practice Address - Country:US
Practice Address - Phone:209-723-9879
Practice Address - Fax:209-384-9027
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341050Medicaid
CAA27373Medicare UPIN
CA00A341050Medicaid