Provider Demographics
NPI:1174160758
Name:RODGERS, ANDREW JAMES
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:RODGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHERRY BARK WAY
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-5542
Mailing Address - Country:US
Mailing Address - Phone:601-668-4010
Mailing Address - Fax:
Practice Address - Street 1:104 CHERRY BARK WAY
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5542
Practice Address - Country:US
Practice Address - Phone:601-668-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800401509172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver