Provider Demographics
NPI:1962449058
Name:MANN, ROGER A (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:MANN
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 1:80 GRAND AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3725
Mailing Address - Country:US
Mailing Address - Phone:510-451-6266
Mailing Address - Fax:
Practice Address - Street 1:80 GRAND AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3725
Practice Address - Country:US
Practice Address - Phone:510-451-6266
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20311207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ79096ZMedicare ID - Type Unspecified
CAA22111Medicare UPIN