Healthcare Provider Details

I. General information

NPI: 1285952408
Provider Name (Legal Business Name): CLEON LOUIS ROGERS IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 1ST AVE S
BIRMINGHAM AL
35212-2522
US

IV. Provider business mailing address

5720 1ST AVE S
BIRMINGHAM AL
35212-2522
US

V. Phone/Fax

Practice location:
  • Phone: 205-380-9455
  • Fax: 205-380-9459
Mailing address:
  • Phone: 205-380-9455
  • Fax: 205-934-9459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31291
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31291
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: