Provider Demographics
NPI:1881608693
Name:HUFFAKER, ROLAND KEITH (M D)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:KEITH
Last Name:HUFFAKER
Suffix:
Gender:M
Credentials:M D
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 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7272
Mailing Address - Fax:423-439-7235
Practice Address - Street 1:1319 SUNSET DR
Practice Address - Street 2:SUITE 103
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-439-7246
Practice Address - Fax:423-282-4698
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD44928207VF0040X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514562Medicaid
TN3714470OtherGROUP MEDICAID #
TN1514562Medicaid