Provider Demographics
NPI:1912906330
Name:ROGERS, CHARLES MITCHELL (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MITCHELL
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 1:1822 E HOLLADAY FARM LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5773
Mailing Address - Country:US
Mailing Address - Phone:801-232-2420
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 4640
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3304
Practice Address - Country:US
Practice Address - Phone:801-387-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162015-1205207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000004359Medicare ID - Type Unspecified
UT000004359Medicare PIN