Healthcare Provider Details

I. General information

NPI: 1790721421
Provider Name (Legal Business Name): TANYA REDDICK RODGERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANYA REDDICK MD

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 RAINTREE CIR SUITE 250
ALLEN TX
75013-4922
US

IV. Provider business mailing address

1101 RAINTREE CIR SUITE 250
ALLEN TX
75013-4922
US

V. Phone/Fax

Practice location:
  • Phone: 972-649-6644
  • Fax: 972-649-6663
Mailing address:
  • Phone: 972-649-6644
  • Fax: 972-649-6663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA08064100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN1109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: