MEDICARE: DR. VICTOR BARRY RODACK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	L 197654	NY

General Provider Information

NPI Number	:	1790752475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTOR BARRY RODACK MD

Provider Business Mailing Address
First Line	:	3421 80TH ST
Second Line	:	APT 31
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-2703
Country	:	US
Telephone Number	:	718-639-3093
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 E 31ST ST
Second Line	:	APT 25L
City	:	NEW YORK
State	:	NY
Zip	:	10016-6800
Country	:	US
Telephone Number	:	212-689-1940
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	07/08/2007

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