Healthcare Provider Details

I. General information

NPI: 1699414763
Provider Name (Legal Business Name): THOMAS ROGERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 159
GROTON CT
06349-5159
US

IV. Provider business mailing address

PO BOX 397
KAHULUI HI
96733-6897
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-2876
  • Fax: 860-694-3874
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0116037098
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102208264
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: