Provider Demographics
NPI:1255828042
Name:ROGERS, MIKELLE B (DO)
Entity Type:Individual
Prefix:
First Name:MIKELLE
Middle Name:B
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DO
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 11720
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1720
Mailing Address - Country:US
Mailing Address - Phone:928-771-5478
Mailing Address - Fax:
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-609-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009184208M00000X
390200000X
NMDO2023-1072208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program