Provider Demographics
NPI:1063697928
Name:RACZ, ROGER STEVEN (DPM)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:STEVEN
Last Name:RACZ
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:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:101 3RD AVE SW
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3880
Practice Address - Country:US
Practice Address - Phone:701-857-3584
Practice Address - Fax:701-857-3566
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.200037213ES0131X
MT171213ES0103X
ND65213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01455275Medicaid
LA2120743Medicaid
LA4P2497061Medicare PIN