Provider Demographics
NPI:1023210317
Name:RODONAIA, GRIGORIY TSOTNEEVICH (MD PA)
Entity Type:Individual
Prefix:
First Name:GRIGORIY
Middle Name:TSOTNEEVICH
Last Name:RODONAIA
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 HARRISON ST
Mailing Address - Street 2:STE. 200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1154
Mailing Address - Country:US
Mailing Address - Phone:409-923-1617
Mailing Address - Fax:409-923-1618
Practice Address - Street 1:2955 HARRISON ST
Practice Address - Street 2:STE. 200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1154
Practice Address - Country:US
Practice Address - Phone:409-923-1617
Practice Address - Fax:409-923-1618
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TX8BX338OtherBCBS
TXPENDINGMedicare UPIN
TX8F21033Medicare PIN