Basic Information
| Provider Information | |||||||||
| NPI: | 1992889661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99371 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851855 | ||||||||
| FaxNumber: | 6828857347 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 RIVERFRONT DR | ||||||||
| Address2: | STE 103 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761076570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173363800 | ||||||||
| FaxNumber: | 8173359454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C8425 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1750369203 | 01 | GRP NPI NUMBER | OTHER | 177056201 | 05 | TX | MEDICAID | 177056202 | 05 | TX | MEDICAID | 86W590 | 01 | TX | BCBSTX IND PIN | OTHER | ROGTE86089 | 01 | TX | CCHIP PIN | OTHER | 00U87Z | 01 | TX | BCBSTX GRP IPN | OTHER | 137345801 | 05 | TX | MEDICAID | 4317664 | 01 | TX | AETNA PIN | OTHER | 123250605 | 05 | TX | MEDICAID | 697562 | 01 | TX | FIRSTHEALTH PIN | OTHER | 123250604 | 05 | TX | MEDICAID | 133997 | 01 | TX | UHC PIN | OTHER | 2877658 | 01 | TX | FIRSTCARE PIN | OTHER |