Provider Demographics
NPI:1659363430
Name:ROCKSTROH, NANCY MOULTRIE (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:MOULTRIE
Last Name:ROCKSTROH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CEDAR RUN DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8156
Mailing Address - Country:US
Mailing Address - Phone:901-215-8485
Mailing Address - Fax:
Practice Address - Street 1:JAX-NAS NAVAL HOSPITAL
Practice Address - Street 2:2080 CHILD STREET
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5000
Practice Address - Country:US
Practice Address - Phone:904-542-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33926207Q00000X
FLME99966207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN122921OtherMISSISSIPPI MEDT
TN3847149Medicaid
TN117415OtherBETTER HEALTH
TN3164959OtherBC BS OF TN
TN080166149OtherRAILROAD MEDICARE
TN14449OtherTLC
TN122921OtherMISSISSIPPI MEDT
TN117415OtherBETTER HEALTH