Provider Demographics
NPI:1073541504
Name:RODMAN, MARK R (ATC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:RODMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WINMAR LN
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1371
Mailing Address - Country:US
Mailing Address - Phone:516-805-5203
Mailing Address - Fax:
Practice Address - Street 1:150 IDLE HOUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1906
Practice Address - Country:US
Practice Address - Phone:631-244-1119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000828-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer