1457360323 NPI number — MR. ROBIN ROUNDTREE

Table of content: MR. ROBIN ROUNDTREE (NPI 1457360323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457360323 NPI number — MR. ROBIN ROUNDTREE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUNDTREE
Provider First Name:
ROBIN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457360323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1341 IDA ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32208-3365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-296-1055
Provider Business Mailing Address Fax Number:
904-448-7700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3725 BELFORT RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-5813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-296-1055
Provider Business Practice Location Address Fax Number:
904-448-7700
Provider Enumeration Date:
08/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)