Provider Demographics
NPI:1134138548
Name:RODD, SAM C (MD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:C
Last Name:RODD
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 1:4221 DALE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193
Mailing Address - Country:US
Mailing Address - Phone:703-670-2176
Mailing Address - Fax:703-730-6268
Practice Address - Street 1:4221 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193
Practice Address - Country:US
Practice Address - Phone:703-670-2176
Practice Address - Fax:703-730-6268
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049843207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6016146Medicaid
VA6016146Medicaid
VAR0519660Medicare ID - Type Unspecified