Healthcare Provider Details

I. General information

NPI: 1740483031
Provider Name (Legal Business Name): ROGER G SCHMIDT PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88TH MEDICAL GROUP/MDOS 4881 SUGAR MAPLE DR.
DAYTON OH
45433-5529
US

IV. Provider business mailing address

88TH MEDICAL GROUP/MDOS 4881 SUGAR MAPLE DRIVE
APO AP
45433
US

V. Phone/Fax

Practice location:
  • Phone: 937-713-1244
  • Fax:
Mailing address:
  • Phone: 937-713-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6785
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberP6785
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: