Provider Demographics
NPI:1144467739
Name:MY GAY DOCTOR, P.C.
Entity type:Organization
Organization Name:MY GAY DOCTOR, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-634-6557
Mailing Address - Street 1:1648 BERKELEY LN NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2731
Mailing Address - Country:US
Mailing Address - Phone:404-634-6557
Mailing Address - Fax:
Practice Address - Street 1:1648 BERKELEY LN NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2731
Practice Address - Country:US
Practice Address - Phone:404-634-6557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48962207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty