Provider Demographics
NPI:1740006550
Name:ROGERS, MADISON R
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:R
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:R
Other - Last Name:MELLIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:1426 LANTRY CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1220
Mailing Address - Country:US
Mailing Address - Phone:407-435-2606
Mailing Address - Fax:
Practice Address - Street 1:1297 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7907
Practice Address - Country:US
Practice Address - Phone:407-435-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT29830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist