Basic Information
| Provider Information | |||||||||
| NPI: | 1578557039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4030 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928344030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149924444 | ||||||||
| FaxNumber: | 7148799999 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 HOSPITAL RD STE 124 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496310988 | ||||||||
| FaxNumber: | 9496312504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 01/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G30212 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G302120 | 05 | CA | MEDICAID |