Provider Demographics
NPI:1134104698
Name:ROEFER, GLENDA SUE (DO)
Entity type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:SUE
Last Name:ROEFER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52537-0067
Mailing Address - Country:US
Mailing Address - Phone:416-643-6216
Mailing Address - Fax:641-664-3690
Practice Address - Street 1:607 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:IA
Practice Address - Zip Code:52537-1516
Practice Address - Country:US
Practice Address - Phone:641-664-3621
Practice Address - Fax:641-664-3690
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-03836207Q00000X
TXL6606207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164561603Medicaid
TX164561603Medicaid
TX8B8691Medicare ID - Type Unspecified