Provider Demographics
NPI:1578559985
Name:KLIGLER, ROGER M (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:M
Last Name:KLIGLER
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 1:1 PEARL ST
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2864
Mailing Address - Country:US
Mailing Address - Phone:508-897-6060
Mailing Address - Fax:508-897-6063
Practice Address - Street 1:1 PEARL ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2864
Practice Address - Country:US
Practice Address - Phone:508-897-6060
Practice Address - Fax:508-897-6063
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA74759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0169218Medicaid
MA0169218Medicaid
MAJ03228Medicare ID - Type Unspecified