Healthcare Provider Details

I. General information

NPI: 1255892618
Provider Name (Legal Business Name): KISHA ROGERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 10/12/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK DR
BENTON AR
72015-3353
US

IV. Provider business mailing address

3359 KRUSE LOOP
ALEXANDER AR
72002-8844
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-6000
  • Fax:
Mailing address:
  • Phone: 479-216-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE16978
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: