Provider Demographics
NPI:1073575858
Name:RODAN, BRUCE ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:RODAN
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 1:3259 UPDIKE AVE
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311
Mailing Address - Country:US
Mailing Address - Phone:850-765-0233
Mailing Address - Fax:
Practice Address - Street 1:3259 UPDIKE AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311
Practice Address - Country:US
Practice Address - Phone:850-765-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0378782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268846800Medicaid
FL268846800Medicaid
FL61244GMedicare PIN
FLD65258Medicare UPIN