Provider Demographics
NPI:1548310543
Name:ROGERS, DWAIN M (MD)
Entity type:Individual
Prefix:DR
First Name:DWAIN
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 302
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-0302
Mailing Address - Country:US
Mailing Address - Phone:814-827-4244
Mailing Address - Fax:814-827-6643
Practice Address - Street 1:406 W OAK ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354-1404
Practice Address - Country:US
Practice Address - Phone:814-827-4244
Practice Address - Fax:814-827-6643
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA34662208600000X
NY196503208600000X
PAMD074183L208600000X
NE24808208600000X
IL036125438208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125438Medicaid
IL036125438Medicaid