Provider Demographics
NPI:1982603668
Name:AMIGO, ROGER G (DO)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:G
Last Name:AMIGO
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 1:2160 EWING CRAWFIS CIR
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-9042
Mailing Address - Country:US
Mailing Address - Phone:937-593-0070
Mailing Address - Fax:937-599-0075
Practice Address - Street 1:2160 EWING CRAWFIS CIR
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-9042
Practice Address - Country:US
Practice Address - Phone:937-593-0070
Practice Address - Fax:937-599-0075
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5016208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340010844OtherRAILROAD MEDICARE PALMETT
OH000000007681OtherANTHAN BCBS
OH310884319033OtherCARESOURCE
OH0836760Medicaid
OH5198086OtherAETNA
OH3980672OtherCIGNA
OH310884319033OtherCARESOURCE
OH340010844OtherRAILROAD MEDICARE PALMETT