Healthcare Provider Details

I. General information

NPI: 1558998211
Provider Name (Legal Business Name): MITCHELL LEE RODEHEAVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 E ASCENSION COMPLEX BLVD
GONZALES LA
70737-4265
US

IV. Provider business mailing address

1112 E ASCENSION COMPLEX BLVD # A
GONZALES LA
70737-4265
US

V. Phone/Fax

Practice location:
  • Phone: 225-450-1016
  • Fax: 225-450-1150
Mailing address:
  • Phone: 225-450-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number322824
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number331055
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: