Provider Demographics
NPI:1003253634
Name:RODENBURG, ANDREW L (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:RODENBURG
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 1:200 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5675
Mailing Address - Country:US
Mailing Address - Phone:701-222-3937
Mailing Address - Fax:
Practice Address - Street 1:200 S 5TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5675
Practice Address - Country:US
Practice Address - Phone:701-222-3937
Practice Address - Fax:701-222-8805
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14294207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1470530Medicaid