Basic Information
| Provider Information | |||||||||
| NPI: | 1881608693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUFFAKER | ||||||||
| FirstName: | ROLAND | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397272 | ||||||||
| FaxNumber: | 4234397235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1319 SUNSET DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234397246 | ||||||||
| FaxNumber: | 4232824698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | MD44928 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VF0040X | MD44928 | TN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1514562 | 05 | TN | MEDICAID | 3714470 | 01 | TN | GROUP MEDICAID # | OTHER |