Provider Demographics
NPI:1073579967
Name:PATNODE, ROGER E (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:E
Last Name:PATNODE
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 1:48 WATER EDGE RD
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-2529
Mailing Address - Country:US
Mailing Address - Phone:518-569-0896
Mailing Address - Fax:
Practice Address - Street 1:48 WATER EDGE RD
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-2529
Practice Address - Country:US
Practice Address - Phone:518-569-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130406-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406515Medicaid
NYBB8757Medicare ID - Type Unspecified
NY00406515Medicaid