Provider Demographics
NPI:1457563983
Name:ROUGHLEY, ROBERT JOHN
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:ROUGHLEY
Suffix:
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 1:166 AVE C
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1417
Mailing Address - Country:US
Mailing Address - Phone:631-467-4388
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2290
Practice Address - Country:US
Practice Address - Phone:631-261-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7314592471R0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation Therapy