Provider Demographics
NPI:1528134046
Name:GOLUB, ROGER J (MD)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:J
Last Name:GOLUB
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 1:112 WOLFF DRIVE
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835
Mailing Address - Country:US
Mailing Address - Phone:907-747-2932
Mailing Address - Fax:
Practice Address - Street 1:209 MOLLER AVE
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-7142
Practice Address - Country:US
Practice Address - Phone:907-747-1701
Practice Address - Fax:907-747-1726
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD8651Medicaid
AK151885Medicare ID - Type Unspecified
AKMD8651Medicaid