MEDICARE: ROGER B ETHINGTON M..D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	552	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679545776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER B ETHINGTON M..D.

Provider Business Mailing Address
First Line	:	4800 N 22ND ST STE 210
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4963
Country	:	US
Telephone Number	:	480-892-8400
Fax Number	:	602-508-4830

Provider Business Practice Location Address
First Line	:	371 W CENTRAL AVE
Second Line	:
City	:	COOLIDGE
State	:	AZ
Zip	:	85128-4706
Country	:	US
Telephone Number	:	520-723-3000
Fax Number	:	520-723-5393

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	07/30/2020

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Directions to “ ROGER B ETHINGTON M..D.” Practice Location

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