Individual
ROGER EWALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
819 BLOOMINGTON RD, CHAMPAIGN, IL 61820-2101
(217) 403-5401
(217) 366-0160
Mailing address
819 BLOOMINGTON RD, CHAMPAIGN, IL 61820-2101
(217) 403-5401
(217) 366-0160
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
036043360
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036043360
LICENSEE PHYSICIAN AND SURGEON
IL
Enumeration date
04/17/2009
Last updated
04/17/2009
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