Healthcare Provider Details

I. General information

NPI: 1265459770
Provider Name (Legal Business Name): RICHARD O ROTHWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 N GLENWOOD BLVD SUITE 415
TYLER TX
75702-5055
US

IV. Provider business mailing address

PO BOX 844273
DALLAS TX
75284-4273
US

V. Phone/Fax

Practice location:
  • Phone: 903-535-9041
  • Fax:
Mailing address:
  • Phone: 903-535-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberD9644
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: