Healthcare Provider Details

I. General information

NPI: 1922127950
Provider Name (Legal Business Name): MARK BRANDON ROGERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 S MAIN ST SUITE A
BLACKSBURG VA
24060-7017
US

IV. Provider business mailing address

3700 S MAIN ST SUITE A
BLACKSBURG VA
24060-7017
US

V. Phone/Fax

Practice location:
  • Phone: 540-443-7180
  • Fax: 540-443-7182
Mailing address:
  • Phone: 540-443-7180
  • Fax: 540-443-7182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102201857
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number116912
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: