Provider Demographics
NPI:1679659791
Name:ROGERS, RANDALL D (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:D
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 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 265
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5609
Mailing Address - Country:US
Mailing Address - Phone:210-224-0402
Mailing Address - Fax:210-593-5992
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 265
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5609
Practice Address - Country:US
Practice Address - Phone:210-224-0402
Practice Address - Fax:210-593-5992
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8863208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036259201Medicaid
TX036259202Medicaid
TX00TZ54Medicare PIN
TX036259201Medicaid