1447903760 NPI number — DOUGLAS RAY ROLLER CDCA

Table of content: DOUGLAS RAY ROLLER CDCA (NPI 1447903760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447903760 NPI number — DOUGLAS RAY ROLLER CDCA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLLER
Provider First Name:
DOUGLAS
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CDCA
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:
1447903760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2216 MCCLEARY JACOBY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORTLAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44410-9426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-984-7475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1628 SPRINGFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45403-1430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-603-5295
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2022

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: 101YA0400X , with the licence number:  CDCA.190856 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 236 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5874 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 96B , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2910854 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 568946544 . This is a "BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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