Healthcare Provider Details

I. General information

NPI: 1528091469
Provider Name (Legal Business Name): HENRY LYLE ROGERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 40TH AVE SUITE 5A
PINE BLUFF AR
71603-6940
US

IV. Provider business mailing address

1801 W 40TH AVE SUITE 5A
PINE BLUFF AR
71603-6940
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-7660
  • Fax: 870-536-6750
Mailing address:
  • Phone: 870-536-7660
  • Fax: 870-536-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC4638
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: