Provider Demographics
NPI:1184631376
Name:ROGERSON, SUSAN HART (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:HART
Last Name:ROGERSON
Suffix:
Gender:F
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:PO BOX 8056
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0001
Mailing Address - Country:US
Mailing Address - Phone:479-841-8878
Mailing Address - Fax:
Practice Address - Street 1:767 W NORTH ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-1865
Practice Address - Country:US
Practice Address - Phone:479-521-3600
Practice Address - Fax:479-521-7422
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR133207001Medicaid
ARG57666Medicare UPIN