Provider Demographics
NPI:1699778126
Name:ROSWELL, ROBERT HOMER (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:HOMER
Last Name:ROSWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 FRONTIER CIR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-2583
Mailing Address - Country:US
Mailing Address - Phone:405-314-4339
Mailing Address - Fax:
Practice Address - Street 1:911 STANTON L. YOUNG BLVD.
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73190-0001
Practice Address - Country:US
Practice Address - Phone:405-271-2307
Practice Address - Fax:450-527-1303
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-30
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10955207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine