Provider Demographics
NPI:1568441269
Name:MANN, ROGER CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:CHARLES
Last Name:MANN
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 1:1619 N GREENWOOD ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2644
Mailing Address - Country:US
Mailing Address - Phone:719-561-4336
Mailing Address - Fax:719-561-8469
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 208
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-561-4336
Practice Address - Fax:719-561-8469
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31281173000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01312818Medicaid
COCN0008Medicare PIN
CON0028Medicare ID - Type Unspecified
CO01312818Medicaid