Provider Demographics
NPI:1134220510
Name:KALLHOVD, ROGER THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:THOMAS
Last Name:KALLHOVD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:114 SOUNDVIEW TER
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1230
Mailing Address - Country:US
Mailing Address - Phone:631-754-7013
Mailing Address - Fax:631-754-7013
Practice Address - Street 1:114 SOUNDVIEW TER
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1230
Practice Address - Country:US
Practice Address - Phone:631-754-7013
Practice Address - Fax:631-754-7013
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1019272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY572992Medicare PIN
NYB16743Medicare UPIN