Provider Demographics
NPI:1720069446
Name:ROGERS, THOMAS G (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W 800 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1624
Mailing Address - Country:US
Mailing Address - Phone:801-375-5353
Mailing Address - Fax:801-375-5395
Practice Address - Street 1:150 W 800 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1624
Practice Address - Country:US
Practice Address - Phone:801-375-5353
Practice Address - Fax:801-375-5395
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103496-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT48832Medicare UPIN
UT000001127Medicare PIN