Provider Demographics
NPI:1972591782
Name:SMALLIGAN, ROGER D (MD, MPH)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:SMALLIGAN
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WALLACE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING DEPT.
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1708
Mailing Address - Country:US
Mailing Address - Phone:806-354-5585
Mailing Address - Fax:806-356-4673
Practice Address - Street 1:301 GOVERNORS DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5123
Practice Address - Country:US
Practice Address - Phone:256-536-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21385207R00000X
TXN4758207R00000X, 208000000X
TN21385208000000X
ALMD.35626207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200263280 AMedicaid
TN4086850Medicaid
TX205346401Medicaid
TX205346403OtherMEDICAID - CSHCN
NM40572889Medicaid
TX205346402Medicaid
TNE82283Medicare UPIN
TX205346403OtherMEDICAID - CSHCN
TX205346402Medicaid