Provider Demographics
NPI:1629008065
Name:RODGERS, BRIAN J (D O)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:J
Last Name:RODGERS
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MEDICAL DRIVE
Mailing Address - Street 2:205
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-298-3812
Mailing Address - Fax:801-294-4434
Practice Address - Street 1:425 MEDICAL DRIVE
Practice Address - Street 2:205
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-298-3812
Practice Address - Fax:801-294-4434
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT30835031204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012309Medicare ID - Type Unspecified
UTG19507Medicare UPIN