Provider Demographics
NPI:1750382503
Name:MOCZYGEMBA, ROGER M (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:M
Last Name:MOCZYGEMBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1010 NW LOOP 410 STE 100A
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2220
Mailing Address - Country:US
Mailing Address - Phone:210-886-8031
Mailing Address - Fax:210-886-8059
Practice Address - Street 1:1010 NW LOOP 410 STE 100A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2220
Practice Address - Country:US
Practice Address - Phone:210-886-8031
Practice Address - Fax:210-886-8059
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ22122083X0100X, 207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ2212OtherTX MEDICAL LICENSE
TXJ2212OtherTX MEDICAL LICENSE
TX144937304Medicaid
TXP00214344OtherRAILROAD MEDICARE
TXJ2212OtherTX MEDICAL LICENSE