Healthcare Provider Details

I. General information

NPI: 1063943587
Provider Name (Legal Business Name): CODY STARK ROGERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE
CONWAY AR
72034-6297
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 501-329-3831
  • Fax:
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-18327
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2019003806
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: