Provider Demographics
NPI:1639191208
Name:DIVIS, ROGER ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALLEN
Last Name:DIVIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-0128
Mailing Address - Country:US
Mailing Address - Phone:405-258-0014
Mailing Address - Fax:405-258-0094
Practice Address - Street 1:910 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-2404
Practice Address - Country:US
Practice Address - Phone:405-258-0014
Practice Address - Fax:405-258-0094
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00135785 DB9021OtherRAILROAD MEDICARE
OK300522106Medicare ID - Type Unspecified
OKP00135785 DB9021OtherRAILROAD MEDICARE