Provider Demographics
NPI:1154038008
Name:ATA, ROGER T
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:T
Last Name:ATA
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 1:15622 N STATE ROAD 79
Mailing Address - Street 2:
Mailing Address - City:EDINBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:46124-9276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15622 N STATE ROAD 79
Practice Address - Street 2:
Practice Address - City:EDINBURGH
Practice Address - State:IN
Practice Address - Zip Code:46124-9276
Practice Address - Country:US
Practice Address - Phone:201-982-0054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030070A183500000X, 1835P1200X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy