Provider Demographics
NPI:1255334769
Name:ON, ROGER C (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
Last Name:ON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 STERN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-4226
Mailing Address - Country:US
Mailing Address - Phone:818-458-7572
Mailing Address - Fax:877-977-7475
Practice Address - Street 1:4835 VAN NUYS BLVD STE 208
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2142
Practice Address - Country:US
Practice Address - Phone:818-946-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40341207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G403410Medicaid
CA00G403410OtherBLUE SHIELD
CA00G403410OtherBLUE SHIELD
CAA89703Medicare UPIN
CAHW13403Medicare PIN
CAWG40341BMedicare PIN
CAWG40341EMedicare PIN
CAWG40341HMedicare PIN
CAHW11358Medicare PIN
CAHW7714Medicare PIN
CA00G403410Medicaid
CAHW13403AMedicare PIN