Provider Demographics
NPI:1558356097
Name:ROGERS, GARY JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 LAKE AVE
Mailing Address - Street 2:SUITE A
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:SUITE 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004888213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021622507OtherBCBS
IL0021622507OtherBCBS
ILU68201Medicare UPIN
ILK50867Medicare PIN