Provider Demographics
NPI:1740483031
Name:SCHMIDT, ROGER G (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:G
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88TH MEDICAL GROUP/MDOS
Mailing Address - Street 2:4881 SUGAR MAPLE DRIVE
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-713-1244
Mailing Address - Fax:
Practice Address - Street 1:88TH MEDICAL GROUP/MDOS
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-713-1244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6785103TC0700X
106E00000X
OHP6785103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0256OtherMEDICARE