Provider Demographics
NPI:1962596148
Name:ROUNDTREE, JOE M (MD)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:M
Last Name:ROUNDTREE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6130
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73506
Mailing Address - Country:US
Mailing Address - Phone:580-536-2121
Mailing Address - Fax:580-536-2150
Practice Address - Street 1:104 NW 31ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-536-2121
Practice Address - Fax:580-536-2150
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12278207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK020003594OtherRAILROAD MEDICARE
OK37D0686457OtherCLIA
OK100123090AMedicaid
OK020003594OtherRAILROAD MEDICARE
OK37D0686457OtherCLIA