Provider Demographics
NPI:1639546765
Name:ROGOW, MARK (AT,C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:ROGOW
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NSWG1 LOGSU MEDICAL SPORTS MEDICINE
Mailing Address - Street 2:3632 GUADALCANAL RD - BLDG #165
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5583
Mailing Address - Country:US
Mailing Address - Phone:619-537-3264
Mailing Address - Fax:
Practice Address - Street 1:NSWG1 LOGSU MEDICAL SPORTS MEDICINE
Practice Address - Street 2:3632 GUADALCANAL RD - BLDG #165
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5583
Practice Address - Country:US
Practice Address - Phone:619-537-3264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer