Basic Information
| Provider Information | |||||||||
| NPI: | 1134115728 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA TORRE | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | ANIBAL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W 119TH ST STE 305 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662093721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133456960 | ||||||||
| FaxNumber: | 9133456966 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738825619 | ||||||||
| FaxNumber: | 5738844611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R3P10 | MO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 203050802 | 05 | MO | MEDICAID | 203050803 | 05 | MO | MEDICAID |