Provider Demographics
NPI:1821167313
Name:ANDERSEN, ROGER S (DO)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:S
Last Name:ANDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 N STEWART
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-4641
Mailing Address - Country:US
Mailing Address - Phone:480-969-7972
Mailing Address - Fax:
Practice Address - Street 1:1923 N TREKELL RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-1706
Practice Address - Country:US
Practice Address - Phone:520-836-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1427204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138026Medicare PIN