Provider Demographics
NPI:1366412181
Name:ROETHEL, RICHARD J (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:ROETHEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3910 TRAVIS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-4783
Mailing Address - Country:US
Mailing Address - Phone:281-485-1896
Mailing Address - Fax:281-485-1896
Practice Address - Street 1:6801 EMMETT F LOWRY EXPY
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2500
Practice Address - Country:US
Practice Address - Phone:409-938-5000
Practice Address - Fax:409-938-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ1374207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89514ZOtherBC/BS PROVIDER NUMBER
TX8012B2Medicare PIN
TX8A0059Medicare PIN
TXF40172Medicare UPIN