Healthcare Provider Details

I. General information

NPI: 1669454690
Provider Name (Legal Business Name): ROGER S. LABONTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 19TH AVE
MERIDIAN MS
39301-4116
US

IV. Provider business mailing address

PO BOX 5183
MERIDIAN MS
39302-5183
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-4078
  • Fax: 601-703-4065
Mailing address:
  • Phone: 601-703-9506
  • Fax: 601-703-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number12417
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12417
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number12417
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: