Provider Demographics
NPI:1225700735
Name:RODGERS, DEMETRIUS
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 WEST KEEFE AVENUE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216
Mailing Address - Country:US
Mailing Address - Phone:414-243-5067
Mailing Address - Fax:
Practice Address - Street 1:6520 W CAPITOL DRIVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216
Practice Address - Country:US
Practice Address - Phone:414-243-5067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-03
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant