Basic Information
| Provider Information | |||||||||
| NPI: | 1154330389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERO | ||||||||
| FirstName: | GRANT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15498 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594554000 | ||||||||
| FaxNumber: | 5594554007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 W VINE ST | ||||||||
| Address2: | SUITE 15 | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093344416 | ||||||||
| FaxNumber: | 2093710119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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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 | 2085R0202X | G63582 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G635820 | 05 | CA | MEDICAID |