Provider Demographics
NPI:1538103189
Name:ROEBUCK, JEREMY CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:CHRISTOPHER
Last Name:ROEBUCK
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 1:740 HOSPITAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4664
Mailing Address - Country:US
Mailing Address - Phone:409-212-8111
Mailing Address - Fax:409-981-1787
Practice Address - Street 1:740 HOSPITAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-4664
Practice Address - Country:US
Practice Address - Phone:409-212-8111
Practice Address - Fax:409-981-1787
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3374207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187037001Medicaid
TXI58914Medicare UPIN
TX8G7546Medicare PIN