Provider Demographics
NPI:1699832667
Name:ROGER, IGNATIUS DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:IGNATIUS
Middle Name:DANIEL
Last Name:ROGER
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 1:91-31 QUEENS BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373
Mailing Address - Country:US
Mailing Address - Phone:718-205-2100
Mailing Address - Fax:
Practice Address - Street 1:91-31 QUEENS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-205-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149774208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Not Answered2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00711739Medicaid
NY68A651Medicare ID - Type UnspecifiedEMPIRE BLUE CROSS
NYB03613Medicare UPIN
NY00711739Medicaid