Provider Demographics
NPI:1639286776
Name:ROESENER, FREMONT FREDERICK (MD)
Entity Type:Individual
Prefix:MR
First Name:FREMONT
Middle Name:FREDERICK
Last Name:ROESENER
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-0417
Mailing Address - Country:US
Mailing Address - Phone:503-842-8877
Mailing Address - Fax:
Practice Address - Street 1:2185 ORCHARD CT
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9432
Practice Address - Country:US
Practice Address - Phone:503-842-4647
Practice Address - Fax:503-842-7617
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09045207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227231Medicaid
OR0011990001OtherREGENCE BLUE CROSS
OR287791Medicaid
C93639Medicare UPIN
OR0011990001OtherREGENCE BLUE CROSS
OR287791Medicaid