Healthcare Provider Details

I. General information

NPI: 1962781617
Provider Name (Legal Business Name): TIMOTHY C ROGERS R.P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23425 HIGHWAY 1084
COVINGTON LA
70435-6652
US

IV. Provider business mailing address

23425 HIGHWAY 1084
COVINGTON LA
70435-6652
US

V. Phone/Fax

Practice location:
  • Phone: 985-893-2006
  • Fax:
Mailing address:
  • Phone: 985-893-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number10 LA 1402
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: