Provider Demographics
NPI:1619288438
Name:BLAIR-ROGERS, MARY (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BLAIR-ROGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BLAIR-GISCOMBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6600 BRUCEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4671
Mailing Address - Country:US
Mailing Address - Phone:916-688-2000
Mailing Address - Fax:
Practice Address - Street 1:6600 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4671
Practice Address - Country:US
Practice Address - Phone:916-688-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72272208000000X
MS22766208000000X
CAA138664302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty