Basic Information
Provider Information | |||||||||
NPI: | 1003896531 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROARK | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | D. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1249 AMBLER AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ABILENE | ||||||||
State: | TX | ||||||||
PostalCode: | 796012351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256772626 | ||||||||
FaxNumber: | 3256776835 | ||||||||
Practice Location | |||||||||
Address1: | 1249 AMBLER AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ABILENE | ||||||||
State: | TX | ||||||||
PostalCode: | 796012351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256772626 | ||||||||
FaxNumber: | 3256776835 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2006 | ||||||||
LastUpdateDate: | 03/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | E4638 | TX | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 110012672 | 01 | TX | RAILROAD MEDICARE | OTHER | 129978601 | 05 | TX |   | MEDICAID | 122579100 | 01 | TX | FIRSTCARE | OTHER |