Provider Demographics
NPI:1790721421
Name:RODGERS, TANYA REDDICK (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:REDDICK
Last Name:RODGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TANYA
Other - Middle Name:
Other - Last Name:REDDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1101 RAINTREE CIR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4922
Mailing Address - Country:US
Mailing Address - Phone:972-649-6644
Mailing Address - Fax:972-649-6663
Practice Address - Street 1:1101 RAINTREE CIR
Practice Address - Street 2:SUITE 250
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4922
Practice Address - Country:US
Practice Address - Phone:972-649-6644
Practice Address - Fax:972-649-6663
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08064100174400000X
TXN1109207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ104495BD8Medicare PIN
NJI63576Medicare UPIN