Provider Demographics
NPI:1487619417
Name:ROGERS, TRENT D (MD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:D
Last Name:ROGERS
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 1:55 WEST TIETAN STREET
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1593
Practice Address - Street 1:55 WEST TIETAN STREET
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-522-1593
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000150925208000000X
WAMD60150941208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
129168OtherBLUE CROSS BLUE SHIELD
MO204956502Medicaid
3269222OtherCIGNA
H13706OtherMERCY
1834225OtherFIRST HEALTH
4435458OtherHEALTHLINK
MO204956502OtherMEDICAID
MO207515500OtherMEDICAID
440546366OtherUNITED HEALTHCARE
MO204956502Medicaid