Provider Demographics
NPI:1366426405
Name:RIEDEL, RODNEY TYSON (MD)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:TYSON
Last Name:RIEDEL
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:PO BOX 34876
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:425-656-4096
Practice Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8350
Practice Address - Country:US
Practice Address - Phone:425-656-5577
Practice Address - Fax:425-656-5595
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042699207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400055637Medicare PIN
I36562Medicare UPIN
NY5537A1Medicare ID - Type Unspecified