Healthcare Provider Details

I. General information

NPI: 1619165420
Provider Name (Legal Business Name): ROGER TRAVIS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27351 DEQUINDRE RD
MADISON HTS MI
48071-3487
US

IV. Provider business mailing address

2424 ROCHESTER RD
ROYAL OAK MI
48073-3633
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-7795
  • Fax:
Mailing address:
  • Phone: 434-250-4862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO 3865
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO 3865
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: