Provider Demographics
NPI:1487693677
Name:ROGERS, GARY (MD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
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 1:300 LONGWOOD AVE
Mailing Address - Street 2:HU-158
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-7384
Mailing Address - Fax:617-738-1657
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:CHILDRENS HOSPITAL DIVISION OF PLASTIC SURGERY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-8509
Practice Address - Fax:617-738-1657
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160060208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0134024Medicaid
G26000Medicare UPIN
A32607Medicare ID - Type Unspecified
MA0134024Medicaid