Provider Demographics
NPI:1649276700
Name:ROGERS, LEIF L (MD)
Entity type:Individual
Prefix:
First Name:LEIF
Middle Name:L
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 1:9735 WILSHIRE BLVD
Mailing Address - Street 2:PH
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2104
Mailing Address - Country:US
Mailing Address - Phone:310-860-8915
Mailing Address - Fax:310-860-8916
Practice Address - Street 1:9735 WILSHIRE BLVD
Practice Address - Street 2:PH
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2104
Practice Address - Country:US
Practice Address - Phone:310-860-8915
Practice Address - Fax:310-860-8916
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2016-05-04
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAA86603174400000X
NY228645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA92318Medicare UPIN