Provider Demographics
NPI:1336118579
Name:HALL, ROGER DWAIN (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DWAIN
Last Name:HALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:CHAPARRAL MEDICAL GROUP
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:790 EAST BONITA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-447-8585
Practice Address - Fax:909-447-8593
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX55070Medicaid
CAW20A5507EMedicare PIN
CA00AX55070Medicare PIN
CA080125031Medicare PIN
CAE49210Medicare UPIN