1134115728 NPI number — ROGER ANIBAL DE LA TORRE M.D.

Table of content: ROGER ANIBAL DE LA TORRE M.D. (NPI 1134115728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134115728 NPI number — ROGER ANIBAL DE LA TORRE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA TORRE
Provider First Name:
ROGER
Provider Middle Name:
ANIBAL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134115728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5701 W 119TH ST STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66209-3721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-345-6960
Provider Business Mailing Address Fax Number:
913-345-6966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65212-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-882-5619
Provider Business Practice Location Address Fax Number:
573-884-4611
Provider Enumeration Date:
09/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  R3P10 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 203050802 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203050803 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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