Provider Demographics
NPI:1770653792
Name:STOUDT, ROGER ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ANDREW
Last Name:STOUDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:358 SAN LORENZO AVE
Mailing Address - Street 2:SUITE 3230
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-1860
Mailing Address - Country:US
Mailing Address - Phone:305-444-6882
Mailing Address - Fax:305-441-9110
Practice Address - Street 1:358 SAN LORENZO AVE
Practice Address - Street 2:SUITE 3230
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-1860
Practice Address - Country:US
Practice Address - Phone:305-444-6882
Practice Address - Fax:305-441-9110
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90202208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270629600Medicaid
11484653OtherCAQH