Provider Demographics
NPI:1740371228
Name:AGRE, RODGER SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:RODGER
Middle Name:SAMUEL
Last Name:AGRE
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 1:880 ALDER AVE
Mailing Address - Street 2:
Mailing Address - City:INCLINE VILLAGE
Mailing Address - State:NV
Mailing Address - Zip Code:89451-8215
Mailing Address - Country:US
Mailing Address - Phone:775-832-5555
Mailing Address - Fax:775-832-5559
Practice Address - Street 1:880 ALDER AVE
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-8215
Practice Address - Country:US
Practice Address - Phone:775-832-5555
Practice Address - Fax:775-832-5559
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMD57402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002013035Medicaid
NV002013035Medicaid
NVC27998Medicare UPIN