Provider Demographics
NPI:1861404709
Name:ROGERS, KATHLEEN M (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 W MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2055
Mailing Address - Country:US
Mailing Address - Phone:220-564-1760
Mailing Address - Fax:220-564-1761
Practice Address - Street 1:1272 W MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2055
Practice Address - Country:US
Practice Address - Phone:220-564-1760
Practice Address - Fax:220-564-1761
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35056491207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0027913OtherTRICARE
OH070006685OtherRR MEDICARE PART B
OH0703733Medicaid
OHH273061Medicare PIN
OH070006685OtherRR MEDICARE PART B
OHH273060Medicare PIN