Provider Demographics
NPI:1093898447
Name:RODEN, JAY S (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:S
Last Name:RODEN
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 1:12200 PARK CENTRAL DR STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75251-2116
Mailing Address - Country:US
Mailing Address - Phone:214-483-9300
Mailing Address - Fax:214-483-9301
Practice Address - Street 1:12200 PARK CENTRAL DR STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2116
Practice Address - Country:US
Practice Address - Phone:214-483-9300
Practice Address - Fax:214-483-9301
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG00192086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1330870-01Medicaid
TX82A504Medicare PIN