Provider Demographics
NPI:1487742201
Name:NELLANS, ROGER E (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:E
Last Name:NELLANS
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 1:1739 BEVERLY AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409
Mailing Address - Country:US
Mailing Address - Phone:928-681-8686
Mailing Address - Fax:928-681-8690
Practice Address - Street 1:1739 E BEVERLY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3593
Practice Address - Country:US
Practice Address - Phone:928-681-8686
Practice Address - Fax:928-681-8690
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA15152208800000X
ORMD28212208800000X
AZ33271208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB13441Medicare ID - Type Unspecified
A95255Medicare UPIN