Healthcare Provider Details

I. General information

NPI: 1578531471
Provider Name (Legal Business Name): JAMES J. ROCKEFELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17101 DALLAS PKWY
ADDISON TX
75001-7103
US

IV. Provider business mailing address

PO BOX 1889
MUNCIE IN
47308-1889
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7729
  • Fax: 505-243-4804
Mailing address:
  • Phone: 505-243-7729
  • Fax: 505-243-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2002-0157
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR9675
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: