Provider Demographics
NPI:1619945110
Name:TABOR, ROSLYN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSLYN
Middle Name:M
Last Name:TABOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8044 SUMMA AVE
Mailing Address - Street 2:BLDG 1 SUITE A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3411
Mailing Address - Country:US
Mailing Address - Phone:225-757-8185
Mailing Address - Fax:225-757-8185
Practice Address - Street 1:8044 SUMMA AVE
Practice Address - Street 2:BLDG 1 SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3411
Practice Address - Country:US
Practice Address - Phone:225-757-8185
Practice Address - Fax:225-757-8185
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1693294Medicaid
LA4E200Medicare PIN
LAD16968Medicare UPIN