Basic Information
Provider Information
NPI: 1003012568
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RODGERS
FirstName: SHAUN
MiddleName: DAVID
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 410 LAKEVILLE RD
Address2: SUITE 204
City: NEW HYDE PARK
State: NY
PostalCode: 110421101
CountryCode: US
TelephoneNumber: 5163543401
FaxNumber: 5163548597
Practice Location
Address1: 410 LAKEVILLE RD
Address2: SUITE 204
City: NEW HYDE PARK
State: NY
PostalCode: 110421101
CountryCode: US
TelephoneNumber: 5163543401
FaxNumber: 5163548597
Other Information
ProviderEnumerationDate: 06/22/2007
LastUpdateDate: 09/09/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207T00000X257509NYY Allopathic & Osteopathic PhysiciansNeurological Surgery 
207T00000X036134910ILN Allopathic & Osteopathic PhysiciansNeurological Surgery 

No ID Information.


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