1477653855 NPI number — DR. KENNETH A ROGERS JR. MD

Table of content: DR. KENNETH A ROGERS JR. MD (NPI 1477653855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477653855 NPI number — DR. KENNETH A ROGERS JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGERS
Provider First Name:
KENNETH
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477653855
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3435 NW 56TH
Provider Second Line Business Mailing Address:
SUITE 711A
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-945-4222
Provider Business Mailing Address Fax Number:
405-945-4322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3435 NW 56TH
Provider Second Line Business Practice Location Address:
SUITE 711A
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-945-4222
Provider Business Practice Location Address Fax Number:
405-945-4322
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  7794 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 040004090 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100212110A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".