Provider Demographics
NPI:1578511663
Name:LIGGETT, ROGER L (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:LIGGETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 HIGHWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1631
Mailing Address - Country:US
Mailing Address - Phone:219-838-3297
Mailing Address - Fax:219-838-3391
Practice Address - Street 1:2940 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:219-838-3297
Practice Address - Fax:219-838-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001493A152W00000X
IN18001493B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100157630Medicaid
IN0283900001Medicare NSC
INT34835Medicare UPIN