Provider Demographics
NPI:1720014434
Name:RODGERS, KEVIN A (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:RODGERS
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 1:1315 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9210
Mailing Address - Country:US
Mailing Address - Phone:802-748-7463
Mailing Address - Fax:802-748-7541
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9210
Practice Address - Country:US
Practice Address - Phone:802-748-7463
Practice Address - Fax:802-748-7541
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0009380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30206051Medicaid
AKHS19OPMedicaid
VT0VN1433Medicaid
AKHS19IPMedicaid
AKHS19OPMedicaid
NH30206051Medicaid