Provider Demographics
NPI:1770024440
Name:ROSER, MARK A (DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ROSER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:323 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3868
Practice Address - Country:US
Practice Address - Phone:513-420-1700
Practice Address - Fax:513-420-9700
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist