Provider Demographics
NPI:1295754075
Name:BOYD, RODERICK RENE (MD)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:RENE
Last Name:BOYD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 WILLOW GREEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-9757
Mailing Address - Country:US
Mailing Address - Phone:870-816-5715
Mailing Address - Fax:
Practice Address - Street 1:460 W OAK ST STE 601
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4538
Practice Address - Country:US
Practice Address - Phone:870-863-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18052208600000X, 207P00000X
PAMD427685208600000X
ARE-2313208600000X
OK32355207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA261891OtherUNISON-WMG
AR139088001Medicaid
PA389133OtherHIGHMARK BLUE SHIELD
PA1022246960001Medicaid
PA823482OtherFIRST PRIORITY HEALTH
AR5N478Medicare ID - Type Unspecified
ARB74397Medicare UPIN
PA1022246960001Medicaid