Provider Demographics
NPI:1558355156
Name:DER, ROGER E (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:DER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3402
Mailing Address - Country:US
Mailing Address - Phone:626-574-3488
Mailing Address - Fax:626-821-6934
Practice Address - Street 1:300 W HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3402
Practice Address - Country:US
Practice Address - Phone:626-574-3488
Practice Address - Fax:626-821-6934
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65753207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A657530Medicaid
CABG781ZMedicare PIN
CAH47345Medicare UPIN
CAA65753Medicare PIN