Provider Demographics
NPI:1326050485
Name:ALLEN, ROOSEVELT (MD)
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4040
Mailing Address - Fax:678-284-4076
Practice Address - Street 1:500 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:770-963-2451
Practice Address - Fax:770-962-0017
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA036083208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA340015405OtherRAILROAD MEDICARE
GA340015405OtherRAILROAD MEDICARE
BA1552149OtherDEA
E19661Medicare UPIN