Healthcare Provider Details

I. General information

NPI: 1740740489
Provider Name (Legal Business Name): GAVIN ROGERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

3522 COLMAR QUARTER
NORFOLK VA
23509-1247
US

V. Phone/Fax

Practice location:
  • Phone: 757-388-3397
  • Fax:
Mailing address:
  • Phone: 757-289-5215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101274475
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: