Healthcare Provider Details

I. General information

NPI: 1770580987
Provider Name (Legal Business Name): DOUGLAS C ROOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 05/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LEW DEWITT BLVD
WAYNESBORO VA
22980
US

IV. Provider business mailing address

6 ROAD 7586
BLOOMFIELD NM
87413-4934
US

V. Phone/Fax

Practice location:
  • Phone: 540-332-5162
  • Fax: 540-332-5875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0040014
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD044326E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101256332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: