Provider Demographics
NPI:1679513360
Name:CORDLE, ROGENA D (MD)
Entity Type:Individual
Prefix:
First Name:ROGENA
Middle Name:D
Last Name:CORDLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROGENA
Other - Middle Name:ANN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW STE 105
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4256
Practice Address - Country:US
Practice Address - Phone:706-291-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043585208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000757072EMedicaid
GA000757072EMedicaid