Provider Demographics
NPI:1982696431
Name:PHILLIPS, ROGER STEVE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:STEVE
Last Name:PHILLIPS
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 1:625 W OLIVE AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-2419
Mailing Address - Country:US
Mailing Address - Phone:209-723-4551
Mailing Address - Fax:209-723-0141
Practice Address - Street 1:625 W OLIVE AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2419
Practice Address - Country:US
Practice Address - Phone:209-723-4551
Practice Address - Fax:209-723-0141
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35984207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB44024FMedicaid
CA942553560OtherTAX IDENTIFICATION NUMBER
CA942553560OtherTAX IDENTIFICATION NUMBER
CAZZZ58613ZMedicare ID - Type Unspecified
CALAB44024FMedicaid