Healthcare Provider Details

I. General information

NPI: 1003046426
Provider Name (Legal Business Name): JOHN L RODAKOWSKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 S. BIRCH STREET
MCCLEARLY WA
98557-9522
US

IV. Provider business mailing address

600 E. MAIN STREET
ELMA WA
98541
US

V. Phone/Fax

Practice location:
  • Phone: 360-495-3244
  • Fax: 360-495-3364
Mailing address:
  • Phone: 360-495-3244
  • Fax: 360-495-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML60096761
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: