Provider Demographics
NPI:1518335843
Name:ROGERS, WILLIS ANTHONY
Entity Type:Individual
Prefix:
First Name:WILLIS
Middle Name:ANTHONY
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 SUMMIT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7773
Mailing Address - Country:US
Mailing Address - Phone:770-712-0661
Mailing Address - Fax:
Practice Address - Street 1:253 SUMMIT VIEW DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7773
Practice Address - Country:US
Practice Address - Phone:770-712-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies