MEDICARE: JOHN C ROOT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	P1136	TX
2	207Q00000X	Family Medicine Physician	20046	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080115102	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	347459101	OTHER	OK	DOL
4	5008436	OTHER	OK	AETNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871589341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN C ROOT MD

Provider Business Mailing Address
First Line	:	1202 FM 3036
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-7798
Country	:	US
Telephone Number	:	361-729-0133
Fax Number	:	361-729-0855

Provider Business Practice Location Address
First Line	:	1202 FM 3036
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-7798
Country	:	US
Telephone Number	:	361-729-0133
Fax Number	:	361-729-0855

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	07/18/2023

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Directions to “ JOHN C ROOT MD” Practice Location

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