Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | J2911 | TX |
N | 207QS0010X | Family Doctor - Sports Medicine | J2911 | TX |
NPI | 1255365276 |
---|---|
Provider Name | Roger L Tolar JR. |
First Address | Keller, TX 76248-3592 |
Second Address | Keller, TX 76248-3592 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2006 |
Last Update Date | 13/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
165367701 | (05) | TX |
G62865 | (02) | TX |