Provider Demographics
NPI:1487630893
Name:ROGERS, NICOLE LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:B
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-758-3598
Mailing Address - Fax:
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-7738
Practice Address - Country:US
Practice Address - Phone:972-758-3598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7556207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029711104Medicaid
TX930128385OtherMEDICARE RAILROAD
TX029711102Medicaid
TX8F4447OtherBCBS
TX930125954OtherMEDICARE RAILROAD
TX029711103Medicaid
TX029711104Medicaid
TX029711103Medicaid
TX930125954OtherMEDICARE RAILROAD
TX930128385OtherMEDICARE RAILROAD