Provider Demographics
NPI:1972738847
Name:ROGERS, JONATHAN STUART (MD, MSC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:STUART
Last Name:ROGERS
Suffix:
Gender:M
Credentials:MD, MSC
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 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24800 SE STARK ST FL 3
Practice Address - Street 2:LEGACY INPATIENT MEDICINE SERVICE
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3378
Practice Address - Country:US
Practice Address - Phone:503-413-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-21
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD158345207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500648364Medicaid
ORR185205Medicare PIN