Provider Demographics
NPI:1538182878
Name:DONENFELD, ROGER FREDERIC (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:FREDERIC
Last Name:DONENFELD
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 1:10557 ROCCA PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077
Mailing Address - Country:US
Mailing Address - Phone:310-471-3777
Mailing Address - Fax:323-209-0010
Practice Address - Street 1:4650 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6306
Practice Address - Country:US
Practice Address - Phone:310-821-5510
Practice Address - Fax:310-822-1826
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48336207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G483360OtherBLUE SHIELD
CA00G483360Medicaid
CA00G483360Medicaid
A59916Medicare UPIN
CAG48336Medicare PIN