Healthcare Provider Details

I. General information

NPI: 1235190760
Provider Name (Legal Business Name): ROGER E ELIAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2006
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COFFEE RD
MODESTO CA
95355-4201
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-521-6097
  • Fax:
Mailing address:
  • Phone: 209-521-6097
  • Fax: 209-521-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC132709
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberC132709
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberC132709
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: