Provider Demographics
NPI:1457336869
Name:NEIST, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:NEIST
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40082OtherSIOUX VALLEY
IA584029Medicaid
MN08-01177OtherMEDICA
MN2712OtherAVERA
MN573R4NEOtherBCBS/MEDICARE SUPPLEMENT
MN120660Medicaid
MN573R4NEOtherBCBS
MN573R4NEMedicaid
MN763472OtherARAZ
MNMH9041000786OtherPPO
MN40082OtherSIOUX VALLEY
D48843Medicare UPIN