Provider Demographics
NPI:1164419180
Name:RODGERS, GEOFFREY D (OPAC)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:D
Last Name:RODGERS
Suffix:
Gender:M
Credentials:OPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-3138
Mailing Address - Country:US
Mailing Address - Phone:913-526-9518
Mailing Address - Fax:931-372-0087
Practice Address - Street 1:105 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3138
Practice Address - Country:US
Practice Address - Phone:913-526-9518
Practice Address - Fax:931-372-0087
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOPA0645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant