Provider Demographics
NPI:1255892618
Name:ROGERS, KISHA (MD)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3359 KRUSE LOOP
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-8844
Mailing Address - Country:US
Mailing Address - Phone:479-216-4368
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3353
Practice Address - Country:US
Practice Address - Phone:501-776-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE16978208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program