Provider Demographics
NPI:1831163385
Name:SMITH, ROGER P (MD)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:P
Last Name:SMITH
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 1:2801 BROOKLINE CT
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1194
Mailing Address - Country:US
Mailing Address - Phone:317-733-8909
Mailing Address - Fax:
Practice Address - Street 1:2801 BROOKLINE CT
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1194
Practice Address - Country:US
Practice Address - Phone:317-733-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117868207V00000X
IN01069201A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203906706Medicaid
IN201014010Medicaid
MO203906706Medicaid
INM400040103Medicare PIN