Provider Demographics
NPI:1033180120
Name:CRIST, RODERIC CLAYTON (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERIC
Middle Name:CLAYTON
Last Name:CRIST
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 1:3095 LEXINGTON AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2602
Mailing Address - Country:US
Mailing Address - Phone:573-339-0004
Mailing Address - Fax:
Practice Address - Street 1:3095 LEXINGTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2602
Practice Address - Country:US
Practice Address - Phone:573-339-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H52207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820571426OtherTRICARE
MO080192016OtherRAILROAD MEDICARE
MO000095535Medicare Oscar/Certification
MO080192016OtherRAILROAD MEDICARE