1154330389 NPI number — GRANT W ROGERO MD

Table of content: GRANT W ROGERO MD (NPI 1154330389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154330389 NPI number — GRANT W ROGERO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROGERO
Provider First Name:
GRANT
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1154330389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-455-4000
Provider Business Mailing Address Fax Number:
559-455-4007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 W VINE ST
Provider Second Line Business Practice Location Address:
SUITE 15
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-334-4416
Provider Business Practice Location Address Fax Number:
209-371-0119
Provider Enumeration Date:
08/05/2006

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: 2085R0202X , with the licence number:  G63582 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G635820 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com