Healthcare Provider Details

I. General information

NPI: 1609862689
Provider Name (Legal Business Name): ROGER JOHN CHARBONEAU D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

1921 STONECIPHER DR
ADA OK
74820-3439
US

V. Phone/Fax

Practice location:
  • Phone: 580-559-0510
  • Fax: 580-272-2715
Mailing address:
  • Phone: 580-559-0510
  • Fax: 580-272-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number4037
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: