Provider Demographics
NPI:1245364330
Name:ROEGNER, DONALD LEE JR (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:LEE
Last Name:ROEGNER
Suffix:JR
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:PO BOX 6459
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-6459
Mailing Address - Country:US
Mailing Address - Phone:765-453-7422
Mailing Address - Fax:765-453-3773
Practice Address - Street 1:702 WEST ALTO ROAD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902
Practice Address - Country:US
Practice Address - Phone:765-453-7422
Practice Address - Fax:765-453-3773
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023409A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100154150AMedicaid
IND69625Medicare UPIN
IN225230AMedicare ID - Type Unspecified