Provider Demographics
NPI:1770580987
Name:ROOT, DOUGLAS C (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:C
Last Name:ROOT
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 1:6 ROAD 7586
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-4934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LEW DEWITT BLVD
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-332-5162
Practice Address - Fax:540-332-5875
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0040014207Q00000X
PAMD044326E207Q00000X
VA0101256332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100728880Medicaid
WV3810006043Medicaid
MD482501200Medicaid
MDS865M574Medicare ID - Type UnspecifiedCMS PROVIDER ID
PA100728880Medicaid
MD211828Medicare ID - Type UnspecifiedFQHC