Provider Demographics
NPI:1104351402
Name:ROGERS, DYLAN RYAN (DO)
Entity type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:RYAN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:024-064-7866
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:2779 W HORIZON RIDGE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4186
Practice Address - Country:US
Practice Address - Phone:702-990-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3325207QS0010X, 207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty