Provider Demographics
NPI:1497953509
Name:RODGERS, DANIEL (IDC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 INDIAN DR APT 63
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5260
Mailing Address - Country:US
Mailing Address - Phone:757-376-7250
Mailing Address - Fax:
Practice Address - Street 1:2ND BN 9TH MAR, 2ND MARINE DIVISION
Practice Address - Street 2:PSC 20002
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0002
Practice Address - Country:US
Practice Address - Phone:910-450-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman