Provider Demographics
NPI:1093235673
Name:ROGACKI, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:ROGACKI
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 1:11516 N PORT WASHINGTON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3478
Mailing Address - Country:US
Mailing Address - Phone:262-241-5040
Mailing Address - Fax:262-241-5261
Practice Address - Street 1:6811 118TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8420
Practice Address - Country:US
Practice Address - Phone:262-857-5700
Practice Address - Fax:262-857-1109
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.070719207R00000X
WI770022085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine