Provider Demographics
NPI:1609862689
Name:CHARBONEAU, ROGER JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:JOHN
Last Name:CHARBONEAU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:580-559-0510
Mailing Address - Fax:580-272-2715
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-559-0510
Practice Address - Fax:580-272-2715
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4037207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200009440AMedicaid
OK611692300OtherOWCP
OKP00212246OtherRAILROAD MEDICARE
OKP00212246OtherRAILROAD MEDICARE
OK248323303Medicare ID - Type Unspecified
OK248323303Medicare Oscar/Certification