Provider Demographics
NPI:1699392985
Name:ROXYANN DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:ROXYANN DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-261-6412
Mailing Address - Street 1:6200 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9037
Mailing Address - Country:US
Mailing Address - Phone:541-261-6412
Mailing Address - Fax:
Practice Address - Street 1:3210 HILLCREST PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7687
Practice Address - Country:US
Practice Address - Phone:541-261-6412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226802Medicaid