Provider Demographics
NPI:1578673489
Name:ROGERS, ANCEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANCEL
Middle Name:J
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1550 E WASHINGTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4624
Mailing Address - Country:US
Mailing Address - Phone:909-370-4400
Mailing Address - Fax:909-422-1588
Practice Address - Street 1:1550 E WASHINGTON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4624
Practice Address - Country:US
Practice Address - Phone:909-370-4400
Practice Address - Fax:909-422-1588
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43151208600000X, 208G00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFM115AMedicare PIN