Provider Demographics
NPI:1073598983
Name:ROGERS, ROBERT LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LANE
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:999 MAR WALT DRIVE
Mailing Address - Street 2:EAST BUILDING
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-863-8255
Mailing Address - Fax:850-862-7965
Practice Address - Street 1:999 MAR WALT DRIVE
Practice Address - Street 2:WHITE-WILSON EAST BUILDING
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-863-8255
Practice Address - Fax:850-862-7965
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME41071208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069716800Medicaid
FL47176OtherBCBSFL
D62494Medicare UPIN
FL069716800Medicaid