Provider Demographics
NPI:1023093655
Name:ROTHROCK, PERRY CLYDE III (MD)
Entity type:Individual
Prefix:DR
First Name:PERRY
Middle Name:CLYDE
Last Name:ROTHROCK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8309 CORDOVA RD
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2046
Mailing Address - Country:US
Mailing Address - Phone:901-757-9984
Mailing Address - Fax:901-757-0536
Practice Address - Street 1:8309 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2046
Practice Address - Country:US
Practice Address - Phone:901-757-9984
Practice Address - Fax:901-757-0536
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37500207Q00000X
ARC 7965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3729650Medicare PIN
TNG 02590Medicare UPIN