Provider Demographics
NPI:1104874676
Name:GIFFORD, ROGER (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:GIFFORD
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 1:1800 BARRS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4704
Mailing Address - Country:US
Mailing Address - Phone:904-388-1562
Mailing Address - Fax:904-399-1841
Practice Address - Street 1:1800 BARRS ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4704
Practice Address - Country:US
Practice Address - Phone:904-388-1562
Practice Address - Fax:904-399-1841
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00159162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35942400Medicaid
FLD61909Medicare UPIN
FL16785Medicare ID - Type Unspecified