Provider Demographics
NPI:1598720948
Name:STROUD, ROLAND RAY JR (MD)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:RAY
Last Name:STROUD
Suffix:JR
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 1:204 WEST HOGAN ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-393-1043
Mailing Address - Fax:931-393-1000
Practice Address - Street 1:204 W HOGAN ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388
Practice Address - Country:US
Practice Address - Phone:931-393-1043
Practice Address - Fax:931-393-1000
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD34529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4056101OtherBCBS
TN3380186Medicaid
TN3380186Medicaid
3380186Medicare ID - Type Unspecified