Provider Demographics
NPI:1558546788
Name:ROATEN, JEFFREY BRENT (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BRENT
Last Name:ROATEN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 LAKE OTIS PKWY STE 312
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5231
Mailing Address - Country:US
Mailing Address - Phone:907-929-7337
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 312
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-929-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN431212086S0120X
AK6550208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1272Medicaid
AK164286Medicare PIN