Provider Demographics
NPI:1447250196
Name:ROGAL, GARY JEFFERY (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:JEFFERY
Last Name:ROGAL
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 1:375 MOUNT PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2724
Mailing Address - Country:US
Mailing Address - Phone:973-731-9442
Mailing Address - Fax:973-731-2918
Practice Address - Street 1:375 MOUNT PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2724
Practice Address - Country:US
Practice Address - Phone:973-731-9442
Practice Address - Fax:973-731-2918
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04745200207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6667902Medicaid
NJ6667902Medicaid
NJ551691Medicare ID - Type Unspecified