1871589341 NPI number — JOHN C ROOT MD

Table of content: JOHN C ROOT MD (NPI 1871589341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871589341 NPI number — JOHN C ROOT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROOT
Provider First Name:
JOHN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1871589341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1202 FM 3036
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKPORT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78382-7798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-729-0133
Provider Business Mailing Address Fax Number:
361-729-0855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 FM 3036
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKPORT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78382-7798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-729-0133
Provider Business Practice Location Address Fax Number:
361-729-0855
Provider Enumeration Date:
09/21/2005

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: 207Q00000X , with the licence number:  P1136 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 20046 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 080115102 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100126830B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 347459101 . This is a "DOL" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 5008436 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100126830A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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