Provider Demographics
NPI:1639185192
Name:ROGERS, BARD L (MD)
Entity Type:Individual
Prefix:
First Name:BARD
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 WEST RD STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2292
Mailing Address - Country:US
Mailing Address - Phone:505-661-8900
Mailing Address - Fax:505-661-8916
Practice Address - Street 1:3917 WEST RD STE A
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-661-8900
Practice Address - Fax:505-661-8976
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0549207Q00000X
NMMD2011-0568207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172322301Medicaid
TX8D0011Medicare PIN
TX00836XMedicare PIN
TXH12854Medicare UPIN