Provider Demographics
NPI:1013916345
Name:ROGERS, DERRICK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:THOMAS
Last Name:ROGERS
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:877-668-5621
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3421
Practice Address - Country:US
Practice Address - Phone:765-284-2172
Practice Address - Fax:765-288-1292
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.084101207Y00000X
IN01066844207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200949350Medicaid
OH2488259Medicaid
INI14797Medicare UPIN
OH2488259Medicaid
INM22404026Medicare PIN