Provider Demographics
NPI:1730134941
Name:ROGERS, JERRY D
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:D
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:P O BOX 638
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372
Mailing Address - Country:US
Mailing Address - Phone:731-925-4902
Mailing Address - Fax:731-925-4445
Practice Address - Street 1:175 J I BELL LANE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372
Practice Address - Country:US
Practice Address - Phone:731-925-4902
Practice Address - Fax:731-925-4445
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN0508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU01198Medicare UPIN
TN0576190001Medicare NSC