Provider Demographics
NPI:1245448752
Name:ROGER D. DUBER D.O., INC.
Entity type:Organization
Organization Name:ROGER D. DUBER D.O., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUBER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-981-8383
Mailing Address - Street 1:685 N 13TH AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4916
Mailing Address - Country:US
Mailing Address - Phone:909-981-8383
Mailing Address - Fax:909-920-3054
Practice Address - Street 1:685 N 13TH AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4916
Practice Address - Country:US
Practice Address - Phone:909-981-8383
Practice Address - Fax:909-920-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4904171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX49040Medicaid
CAE08835Medicare UPIN
CA020A49040Medicare ID - Type UnspecifiedMEDICARE PROVIDER