Provider Demographics
NPI:1932460615
Name:ROGERS, DARYL PAUL
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:PAUL
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 S HAM LN STE A
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3530
Mailing Address - Country:US
Mailing Address - Phone:209-333-2020
Mailing Address - Fax:209-333-1188
Practice Address - Street 1:541 S HAM LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3530
Practice Address - Country:US
Practice Address - Phone:209-333-2020
Practice Address - Fax:209-333-1188
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2996237700000X
CASL4692156F00000X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician