Provider Demographics
NPI:1790020345
Name:ROGERS, WALTER REGINALD SR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:REGINALD
Last Name:ROGERS
Suffix:SR
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 1:1046 E 82ND ST
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4224
Mailing Address - Country:US
Mailing Address - Phone:347-673-8825
Mailing Address - Fax:
Practice Address - Street 1:1046 E 82ND ST
Practice Address - Street 2:APARTMENT 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4224
Practice Address - Country:US
Practice Address - Phone:347-673-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY281500-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program