Healthcare Provider Details

I. General information

NPI: 1528096591
Provider Name (Legal Business Name): ROGER FABIAN ANDERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 GOVERNOR MANLY WAY SUITE 102
RALEIGH NC
27614-8595
US

IV. Provider business mailing address

11200 GOVERNOR MANLY WAY SUITE 102
RALEIGH NC
27614-8595
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-7550
  • Fax: 919-570-7551
Mailing address:
  • Phone: 919-570-7550
  • Fax: 919-570-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number30738
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number39233
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: