Provider Demographics
NPI:1801994017
Name:ROESLER, MARK ALDERSON (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALDERSON
Last Name:ROESLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11638 W FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6723
Mailing Address - Country:US
Mailing Address - Phone:314-838-2220
Mailing Address - Fax:314-838-8161
Practice Address - Street 1:11638 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6723
Practice Address - Country:US
Practice Address - Phone:314-838-2220
Practice Address - Fax:314-838-8161
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005161111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4400116OtherUNITED HEALTHCARE
MO431429608ROtherMERCY
MO12448OtherBLUE CROSS BLUE SHIELD
MO140674900OtherDEPT OF LABOR
MO000031172Medicare ID - Type Unspecified
MO140674900OtherDEPT OF LABOR