Provider Demographics
NPI:1063112522
Name:CARTER SR., ROGER DOMINIQUE
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DOMINIQUE
Last Name:CARTER SR.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6240 STOCKTON TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-4464
Mailing Address - Country:US
Mailing Address - Phone:614-537-9808
Mailing Address - Fax:
Practice Address - Street 1:6240 STOCKTON TRAIL WAY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4464
Practice Address - Country:US
Practice Address - Phone:614-537-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH92-2538873Medicaid