Provider Demographics
NPI:1699709055
Name:ROEGIERS, GARY VINCENT (PT, DC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:VINCENT
Last Name:ROEGIERS
Suffix:
Gender:M
Credentials:PT, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3606
Mailing Address - Country:US
Mailing Address - Phone:860-347-1302
Mailing Address - Fax:860-347-1305
Practice Address - Street 1:80 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-347-1302
Practice Address - Fax:860-347-1305
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003388225100000X
CT001332111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000504Medicare PIN