Provider Demographics
NPI:1114961190
Name:RODEBAUGH, MARIA R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:R
Last Name:RODEBAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D' ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:1919 LINCOLN WAY
Practice Address - Street 2:211
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-5500
Practice Address - Fax:208-625-5501
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM11187207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117833400Medicaid
WY117833400Medicaid
WY9305Medicare ID - Type Unspecified