Provider Demographics
NPI:1649245499
Name:WOBIG, ROGER JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:JOHN
Last Name:WOBIG
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:24076 SE STARK ST
Practice Address - Street 2:SUITE 230
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3373
Practice Address - Country:US
Practice Address - Phone:503-488-2600
Practice Address - Fax:503-465-5468
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21899207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR134373Medicaid
WA8255622Medicaid
ORH00015Medicare UPIN
OR134406Medicare PIN