Healthcare Provider Details

I. General information

NPI: 1548367337
Provider Name (Legal Business Name): ROGER D MAYO L.D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 LEE HWY SUITE 108
CHATTANOOGA TN
37421-2490
US

IV. Provider business mailing address

6940 LEE HWY SUITE 108
CHATTANOOGA TN
37421-2490
US

V. Phone/Fax

Practice location:
  • Phone: 423-892-4900
  • Fax: 423-855-1496
Mailing address:
  • Phone: 423-892-4900
  • Fax: 423-855-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number409
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: