Basic Information
| Provider Information | |||||||||
| NPI: | 1821032277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONDA | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1108 | ||||||||
| Address2: | ATTENTION: LYNDA THOMPSON | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481061108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346777400 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Practice Location | |||||||||
| Address1: | 6245 INKSTER RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481354001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344583412 | ||||||||
| FaxNumber: | 7346777407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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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 | 2085R0202X | 4301047458 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4437744 | 05 | MI | MEDICAID |