Healthcare Provider Details

I. General information

NPI: 1811963499
Provider Name (Legal Business Name): ROGER LEROY CRONK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 CONSTITUTION PLACE NE #202
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

8020 CONSTITUTION PLACE NE #202
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-3096
  • Fax: 505-998-3100
Mailing address:
  • Phone: 505-998-3096
  • Fax: 505-998-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA71580
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA71580
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: