Provider Demographics
NPI:1245449461
Name:OGHLAKIAN, ROGER OHANES (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:OHANES
Last Name:OGHLAKIAN
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 1:2115 S FREMONT AVE STE 3000
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2215
Mailing Address - Country:US
Mailing Address - Phone:417-829-9123
Mailing Address - Fax:417-820-3935
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:STE 3000
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-9123
Practice Address - Fax:417-820-3935
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.011624207R00000X
MO20110039402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MO1245449461Medicaid
AR187910001Medicaid
MOP00954926OtherRR MCR
MOP00954926OtherRR MCR
AR187910001Medicaid