Provider Demographics
NPI:1508049404
Name:GARY ROGERS DPM
Entity Type:Organization
Organization Name:GARY ROGERS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-256-4434
Mailing Address - Street 1:1921 LAKE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1480
Mailing Address - Country:US
Mailing Address - Phone:847-256-4434
Mailing Address - Fax:847-256-4437
Practice Address - Street 1:1921 LAKE AVE
Practice Address - Street 2:STE A
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1480
Practice Address - Country:US
Practice Address - Phone:847-256-4434
Practice Address - Fax:847-256-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5220730001Medicare NSC