Provider Demographics
NPI:1679620348
Name:ROGOWSKI, JOHN PETER JR (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
Last Name:ROGOWSKI
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4202
Mailing Address - Country:US
Mailing Address - Phone:203-367-5589
Mailing Address - Fax:203-330-0838
Practice Address - Street 1:2819 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4202
Practice Address - Country:US
Practice Address - Phone:203-367-5589
Practice Address - Fax:203-330-0838
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001793103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT338435OtherVALUEOPTIONS
CTP00039160OtherRAILROAD MEDICARE
CT0001107167OtherMHN
CT060001793CT02OtherANTHEM, BCBS,