Provider Demographics
NPI:1043395668
Name:ROGERS, LARRY CALVIN (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:CALVIN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:ALTA
Other - Middle Name:FAYE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-0007
Mailing Address - Country:US
Mailing Address - Phone:304-257-4511
Mailing Address - Fax:304-257-4511
Practice Address - Street 1:7 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-0007
Practice Address - Country:US
Practice Address - Phone:304-257-4511
Practice Address - Fax:304-257-4511
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV10484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0055759000Medicaid
WV0055759000Medicaid
WV9162681Medicare ID - Type Unspecified