Healthcare Provider Details

I. General information

NPI: 1881608693
Provider Name (Legal Business Name): ROLAND KEITH HUFFAKER M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 SUNSET DR SUITE 103
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

PO BOX 699
MOUNTAIN HOME TN
37684-0699
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-7246
  • Fax: 423-282-4698
Mailing address:
  • Phone: 423-439-7272
  • Fax: 423-439-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberMD44928
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD44928
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: