Provider Demographics
NPI:1659323111
Name:ROGERS, WAYNE GLENN (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:GLENN
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 1:3B CLEVELAND CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2414
Mailing Address - Country:US
Mailing Address - Phone:864-232-0196
Mailing Address - Fax:864-351-0373
Practice Address - Street 1:3B CLEVELAND CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2414
Practice Address - Country:US
Practice Address - Phone:864-232-0196
Practice Address - Fax:864-351-0373
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6924207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP0198Medicaid
SCC61095Medicare UPIN
SCC610951954Medicare ID - Type Unspecified