Provider Demographics
NPI:1295956902
Name:RODGERS, CHARLES L (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:L
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 1:2201 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3121
Mailing Address - Country:US
Mailing Address - Phone:706-320-9012
Mailing Address - Fax:706-320-9021
Practice Address - Street 1:2201 BUENA VISTA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3121
Practice Address - Country:US
Practice Address - Phone:706-320-9012
Practice Address - Fax:706-320-9021
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030202207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00354021-AMedicaid
GAA02883Medicare UPIN
GA11BDBQSMedicare ID - Type Unspecified