Provider Demographics
NPI:1023169612
Name:RODEN, JON (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:RODEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GOODYEAR AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1195
Mailing Address - Country:US
Mailing Address - Phone:256-494-4768
Mailing Address - Fax:256-494-4793
Practice Address - Street 1:1007 GOODYEAR AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1195
Practice Address - Country:US
Practice Address - Phone:256-494-4768
Practice Address - Fax:256-494-4793
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL27589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1023169612Medicaid
AL1023169612Medicaid
5101080271Medicare PIN