Provider Demographics
NPI:1245490796
Name:MILBRY, ROELL T JR
Entity type:Individual
Prefix:MR
First Name:ROELL
Middle Name:T
Last Name:MILBRY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23277
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-3277
Mailing Address - Country:US
Mailing Address - Phone:904-982-2407
Mailing Address - Fax:
Practice Address - Street 1:8700 SOUTHSIDE BLVD APT 313
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8478
Practice Address - Country:US
Practice Address - Phone:904-982-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL687829696Medicaid