Provider Demographics
NPI:1043779275
Name:RODESKY, JEREMY SCOTT
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:RODESKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E GLEN MARE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-8772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 MDG
Practice Address - Street 2:UNIT 3690
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126
Practice Address - Country:US
Practice Address - Phone:913-702-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians