Provider Demographics
NPI:1043316169
Name:ROGERS, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:6100 PAN AMERICAN EAST FWY NE
Mailing Address - Street 2:100
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3427
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:6100 PAN AMERICAN EAST FWY NE
Practice Address - Street 2:100
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3427
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80242173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00017236Medicaid
NM00017236Medicaid
NM2130628Medicare PIN