Provider Demographics
NPI:1942224217
Name:ROSSOMONDO, ROGER M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:M
Last Name:ROSSOMONDO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:158 CLINIC AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4414
Mailing Address - Country:US
Mailing Address - Phone:770-834-1008
Mailing Address - Fax:770-834-2531
Practice Address - Street 1:158 CLINIC AVE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4414
Practice Address - Country:US
Practice Address - Phone:770-834-1008
Practice Address - Fax:770-834-2531
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA013925207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000091253CMedicaid
GA000091253BMedicaid
GAD30656Medicare UPIN
GA18BDCWJMedicare PIN