Provider Demographics
NPI:1972613826
Name:VARDELEON, ROGER V (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:V
Last Name:VARDELEON
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 1:327 CONWAY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8114
Mailing Address - Country:US
Mailing Address - Phone:314-576-4042
Mailing Address - Fax:314-576-4042
Practice Address - Street 1:327 CONWAY LAKE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8114
Practice Address - Country:US
Practice Address - Phone:314-576-4042
Practice Address - Fax:314-576-4042
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4094208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200138915Medicaid
MOA25416Medicare UPIN
MO000003480Medicare ID - Type Unspecified