Provider Demographics
NPI:1871546051
Name:HOUSE, ROGER DALE (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:HOUSE
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 1:2401 SUMMERHILL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-3570
Mailing Address - Country:US
Mailing Address - Phone:903-792-4779
Mailing Address - Fax:903-792-4693
Practice Address - Street 1:2401 SUMMERHILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-3570
Practice Address - Country:US
Practice Address - Phone:903-792-4779
Practice Address - Fax:903-792-4693
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1153256-04Medicaid
AR102969001Medicaid
AR102969001Medicaid
TX1153256-04Medicaid
TX00K81FMedicare ID - Type Unspecified