Provider Demographics
NPI:1487317814
Name:HART, RODNEY JEROME
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:JEROME
Last Name:HART
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RAUDNI
Other - Middle Name:
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 88514
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96830-8514
Mailing Address - Country:US
Mailing Address - Phone:808-376-9411
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:855-832-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-178898106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI9552012OtherMEDICAL