Provider Demographics
NPI:1063621720
Name:MACURA, ROGER S (DPM)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:MACURA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 LOS ANGELES AVE
Mailing Address - Street 2:#256
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-7500
Mailing Address - Country:US
Mailing Address - Phone:805-527-4686
Mailing Address - Fax:
Practice Address - Street 1:690 LOS ANGELES AVE
Practice Address - Street 2:#256
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-7500
Practice Address - Country:US
Practice Address - Phone:805-527-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2139213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T11195Medicare UPIN