Provider Demographics
NPI:1679571988
Name:ROGERS, JACK A JR (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ROGERS
Suffix:JR
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 1:114 PLANTATION AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2370
Mailing Address - Country:US
Mailing Address - Phone:678-901-0717
Mailing Address - Fax:678-901-0718
Practice Address - Street 1:114 PLANTATION AVE
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2370
Practice Address - Country:US
Practice Address - Phone:678-901-0717
Practice Address - Fax:678-901-0718
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 017875208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA625778716BMedicaid
D40996Medicare UPIN
37BBGKXMedicare ID - Type Unspecified