Provider Demographics
NPI:1558355156
Name:DER, ROGER E (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:DER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2311
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91313-2311
Mailing Address - Country:US
Mailing Address - Phone:818-718-9500
Mailing Address - Fax:818-718-9507
Practice Address - Street 1:23845 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2001
Practice Address - Country:US
Practice Address - Phone:661-253-8504
Practice Address - Fax:661-253-8647
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA65753207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657530Medicaid
CABG781ZMedicare PIN
CAH47345Medicare UPIN
CAA65753Medicare PIN