Provider Demographics
NPI:1689170243
Name:ROG, COLIN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:JOSEPH
Last Name:ROG
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 1:747 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4307
Mailing Address - Country:US
Mailing Address - Phone:206-215-4253
Mailing Address - Fax:
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122
Practice Address - Country:US
Practice Address - Phone:206-215-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60856516208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery