Provider Demographics
NPI:1629617402
Name:DOAK, ROGER A (AT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:DOAK
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7222 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-8678
Mailing Address - Country:US
Mailing Address - Phone:616-780-1188
Mailing Address - Fax:
Practice Address - Street 1:1100 IONIA RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1035
Practice Address - Country:US
Practice Address - Phone:616-780-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010004862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer