Healthcare Provider Details

I. General information

NPI: 1366426405
Provider Name (Legal Business Name): RODNEY TYSON RIEDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26458 MAPLE VALLEY BLACK DIAMOND RD SE
MAPLE VALLEY WA
98038-8350
US

IV. Provider business mailing address

PO BOX 34876
RENTON WA
98055
US

V. Phone/Fax

Practice location:
  • Phone: 425-656-5577
  • Fax: 425-656-5595
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD00042699
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00042699
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: