Provider Demographics
NPI:1427039916
Name:RODGERS, VANCE D (MD)
Entity Type:Individual
Prefix:
First Name:VANCE
Middle Name:D
Last Name:RODGERS
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 1:1400 E. CHURCH STREET
Mailing Address - Street 2:ATTENTION- MEDICAL STAFF OFFICE
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-739-3954
Mailing Address - Fax:805-739-3060
Practice Address - Street 1:1551 BISHOP ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4661
Practice Address - Country:US
Practice Address - Phone:805-434-5530
Practice Address - Fax:805-786-4220
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44433207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G444330Medicaid
CAG44433OtherMEDICAL LICENSE NUMBER
CABR2862200OtherDEA NUMBER
CA1037OtherCMSP NUMBER
CAG44433OtherMEDICAL LICENSE NUMBER
CA00G444330Medicaid
CABR2862200OtherDEA NUMBER
CAY17093Medicare UPIN