Provider Demographics
NPI:1689732091
Name:NASH, ROGER WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:WADE
Last Name:NASH
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 1:165 WAYMONT COURT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746
Mailing Address - Country:US
Mailing Address - Phone:407-321-3012
Mailing Address - Fax:407-321-9006
Practice Address - Street 1:165 WAYMONT COURT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746
Practice Address - Country:US
Practice Address - Phone:407-321-3012
Practice Address - Fax:407-321-9006
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30781174400000X
FL307812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252142300Medicaid
FL47410Medicare ID - Type Unspecified
FLD55045Medicare UPIN