Healthcare Provider Details

I. General information

NPI: 1033630124
Provider Name (Legal Business Name): JOHN ROXBOROUGH IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 BENNING RD NE
WASHINGTON DC
20019-4555
US

IV. Provider business mailing address

555 MOUNTCASTLE RD
SPRINGFIELD IL
62704-1597
US

V. Phone/Fax

Practice location:
  • Phone: 202-388-7891
  • Fax: 202-548-8600
Mailing address:
  • Phone: 202-207-6929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.070326
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0089405
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD048736
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: