Healthcare Provider Details

I. General information

NPI: 1457312753
Provider Name (Legal Business Name): TAIYUN ROE M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 MILITARY W SUITE 101
BENICIA CA
94510-2451
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 707-745-0711
  • Fax: 707-745-0788
Mailing address:
  • Phone: 925-370-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA85651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: