Provider Demographics
NPI:1609863299
Name:FELLOWS, ROGER D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:D
Last Name:FELLOWS
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 1:68-1375 S PAUOA RD APT Q1
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8726
Mailing Address - Country:US
Mailing Address - Phone:808-885-7025
Mailing Address - Fax:808-885-7025
Practice Address - Street 1:67-1125 MAMALAHOA HWY
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8496
Practice Address - Country:US
Practice Address - Phone:808-881-4881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2009-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149047-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT03831Medicaid
UT000010378Medicare ID - Type Unspecified
UT03831Medicaid
AZZ114362Medicare PIN