Provider Demographics
NPI:1942218359
Name:RODGERS, JERRY WHARTON (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WHARTON
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:18780 INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-3593
Practice Address - Country:US
Practice Address - Phone:903-567-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD5180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039171607Medicaid
TXP01069945OtherRAIL ROAD
TX752616977028OtherTRICARE
TX752616977001OtherTRICARE
TX86426FOtherBCBS
TX8V0575OtherBCBS OF TEXAS
TX039171606Medicaid
TX1701864-01Medicaid
TXP00467568Medicare PIN
TX8J3853Medicare PIN
TX8V0575OtherBCBS OF TEXAS
TX752616977028OtherTRICARE
TXP01069945OtherRAIL ROAD
TXTXB154299Medicare Oscar/Certification