Provider Demographics
NPI:1295749455
Name:ROLLER, JENNIFER R (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:ROLLER
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 1:36739 SR 52
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-5101
Mailing Address - Country:US
Mailing Address - Phone:813-333-5233
Mailing Address - Fax:813-940-3234
Practice Address - Street 1:36739 SR 52
Practice Address - Street 2:SUITE 101
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5101
Practice Address - Country:US
Practice Address - Phone:813-333-5233
Practice Address - Fax:813-940-3234
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105900207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01205219OtherR&R MEDICARE
FL002822300Medicaid
FL002822300Medicaid