Provider Demographics
NPI:1376574160
Name:ROGER, JEFFREY PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PHILIP
Last Name:ROGER
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 1:745 W MOANA LN STE 300
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4980
Mailing Address - Country:US
Mailing Address - Phone:970-640-7000
Mailing Address - Fax:
Practice Address - Street 1:745 W MOANA LN STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-4980
Practice Address - Country:US
Practice Address - Phone:970-640-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20736207RH0002X
WAMD00044507207RH0002X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1091581Medicaid
WA8420648Medicaid
WA8420648Medicaid
CO505868Medicare ID - Type UnspecifiedCWEP
WAH90383Medicare UPIN