Provider Demographics
NPI:1649002023
Name:ROE, ERIC JONATHAN
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JONATHAN
Last Name:ROE
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:PO BOX 133
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:45360-0133
Mailing Address - Country:US
Mailing Address - Phone:937-424-6678
Mailing Address - Fax:
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:45360-1007
Practice Address - Country:US
Practice Address - Phone:937-424-6678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant