Provider Demographics
NPI:1972696912
Name:ROGERS, SUNDANCE L (MD)
Entity Type:Individual
Prefix:
First Name:SUNDANCE
Middle Name:L
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 WINTERGREEN LN NE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5118
Mailing Address - Country:US
Mailing Address - Phone:206-842-5632
Mailing Address - Fax:206-842-5992
Practice Address - Street 1:1344 WINTERGREEN LN NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110
Practice Address - Country:US
Practice Address - Phone:206-842-5632
Practice Address - Fax:206-842-5992
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6701ROOtherBLUE SHIELD #
WA8192486Medicaid
WAUS0900037OtherAETNA PCP PIN
WA0039581OtherLABOR AND INDUSTRIES #
WAUS0819159OtherAETNA SPECIALIST PIN
WA110217394OtherRAILROAD MEDICARE
WAUS0900037OtherAETNA PCP PIN
WA110217394OtherRAILROAD MEDICARE
WA8192486Medicaid
WA6701ROOtherBLUE SHIELD #