Provider Demographics
NPI:1992740179
Name:MOLER, RODGER EUGENE (DO)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:EUGENE
Last Name:MOLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S RIDGECREST
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714
Mailing Address - Country:US
Mailing Address - Phone:417-725-8250
Mailing Address - Fax:417-724-3185
Practice Address - Street 1:105 S RIDGECREST
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714
Practice Address - Country:US
Practice Address - Phone:417-725-8250
Practice Address - Fax:417-724-3185
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176410003Medicaid
MO241039445Medicaid
MO1992410179Medicaid
080036692OtherRR MEDICARE
MO241039445Medicaid
AR5H374G073Medicare PIN
941710115Medicare ID - Type Unspecified
001013001Medicare ID - Type Unspecified
MO1992410179Medicaid
OK200237770 AMedicare PIN