Provider Demographics
NPI:1437247293
Name:KINNARD, ROGER L (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:L
Last Name:KINNARD
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 1:792 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-2710
Mailing Address - Country:US
Mailing Address - Phone:781-665-2255
Mailing Address - Fax:781-665-2246
Practice Address - Street 1:792 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-2710
Practice Address - Country:US
Practice Address - Phone:781-665-2255
Practice Address - Fax:781-665-2246
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59856207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3039897Medicaid
MAJ07834Medicare ID - Type Unspecified
MAA14268Medicare UPIN