Provider Demographics
NPI:1902009699
Name:GADDIS, ROGER DALE (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:GADDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 MORGANTON SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4796
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:266 JOULE ST
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2422
Practice Address - Country:US
Practice Address - Phone:865-984-3864
Practice Address - Fax:865-380-4095
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDO0000001730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4334952Medicaid
TN1513698Medicaid
TN10308I6014Medicare PIN