Provider Demographics
NPI:1285786210
Name:ROSENQUIST, ROGER DALE (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:ROSENQUIST
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 1:501 N GRAHAM ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1654
Mailing Address - Country:US
Mailing Address - Phone:503-288-7303
Mailing Address - Fax:503-288-3806
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 342
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2448
Practice Address - Country:US
Practice Address - Phone:503-255-5244
Practice Address - Fax:503-255-5120
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12426208800000X
CAG25411208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR135491Medicaid
ORR102836Medicare ID - Type Unspecified
A42657Medicare UPIN