Provider Demographics
NPI:1013011626
Name:ROEBUCK, JONATHAN D
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:ROEBUCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:ROEBUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:DWIGHT DAVID EISENHOWER AMC
Mailing Address - Street 2:300 E HOSPITAL RD
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-0001
Mailing Address - Country:US
Mailing Address - Phone:706-787-4154
Mailing Address - Fax:
Practice Address - Street 1:DWIGHT DAVID EISENHOWER AMC
Practice Address - Street 2:300 E HOSPITAL RD
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-0001
Practice Address - Country:US
Practice Address - Phone:706-787-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78234207RR0500X
MT59182207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology