Provider Demographics
NPI:1619920675
Name:ROH, DAEYOUNG D (MD)
Entity Type:Individual
Prefix:
First Name:DAEYOUNG
Middle Name:D
Last Name:ROH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:ROH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:15492 E PRENTICE DR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4267
Mailing Address - Country:US
Mailing Address - Phone:817-296-9180
Mailing Address - Fax:817-421-6252
Practice Address - Street 1:15492 E PRENTICE DR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-4267
Practice Address - Country:US
Practice Address - Phone:817-296-9180
Practice Address - Fax:817-421-6252
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0051910207R00000X
CAG62251207R00000X, 208M00000X
TXM3075207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179849805Medicaid
TX179849802Medicaid
TX179849803Medicaid
TX179849801Medicaid
TX8S5106OtherBCBS
CO63503514OtherMEDICAID
TX179849805Medicaid
TX8S5106OtherBCBS
TX8L8921Medicare PIN
TXTXB112090Medicare PIN
TX8G5506Medicare PIN
TX8L8932Medicare PIN
CO399243Medicare PIN