Provider Demographics
NPI:1922160373
Name:VANORSDOLL, ROGER J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
Last Name:VANORSDOLL
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 1:53793 CRYSTAL CREEK LN
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3053
Mailing Address - Country:US
Mailing Address - Phone:574-264-3309
Mailing Address - Fax:
Practice Address - Street 1:3100 WINDSOR CT
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5556
Practice Address - Country:US
Practice Address - Phone:574-206-8800
Practice Address - Fax:574-206-8806
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030025A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01030025AOtherMEDICAL LICENCING BOARD
IN01030025AOtherMEDICAL LICENCING BOARD