Healthcare Provider Details

I. General information

NPI: 1013011626
Provider Name (Legal Business Name): JONATHAN D ROEBUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHAN ROEBUCK MD

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/01/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DWIGHT DAVID EISENHOWER AMC 300 E HOSPITAL RD
FORT GORDON GA
30905-0001
US

IV. Provider business mailing address

DWIGHT DAVID EISENHOWER AMC 300 E HOSPITAL RD
FORT GORDON GA
30905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-4154
  • Fax:
Mailing address:
  • Phone: 706-787-4154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number78234
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number59182
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: