Provider Demographics
NPI:1073122438
Name:ROGERS, KEVIN LEE (RDN)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:ROGERS
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 TASMAN DR SPC 685
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94089-5784
Mailing Address - Country:US
Mailing Address - Phone:408-469-1630
Mailing Address - Fax:
Practice Address - Street 1:1085 TASMAN DR SPC 685
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94089-5784
Practice Address - Country:US
Practice Address - Phone:408-469-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86090853133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered