Healthcare Provider Details

I. General information

NPI: 1114499779
Provider Name (Legal Business Name): ROODOLPH JOSEPH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 JEFFERSON BLVD
WARWICK RI
02888-1027
US

IV. Provider business mailing address

110 ELM ST FL 3
PROVIDENCE RI
02903-4626
US

V. Phone/Fax

Practice location:
  • Phone: 401-941-2830
  • Fax:
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-537-7241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number023160
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01507
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: