Provider Demographics
NPI:1124058094
Name:DAVIS, ROGER W (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:W
Last Name:DAVIS
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:PO BOX 9000
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-2206
Mailing Address - Fax:719-553-2226
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-2206
Practice Address - Fax:719-553-2226
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30919207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01309194Medicaid
CO1124058094OtherNPI
E86718Medicare UPIN