Provider Demographics
NPI:1164432696
Name:ROEDER, ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROEDER
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 1:315 N SAN SABA
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3100
Mailing Address - Country:US
Mailing Address - Phone:210-704-3391
Mailing Address - Fax:210-704-4520
Practice Address - Street 1:333 N. SANTA ROSA ST.
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207
Practice Address - Country:US
Practice Address - Phone:210-704-3391
Practice Address - Fax:210-704-4520
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9458208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161251702OtherCIDC
TX161251701Medicaid
TX161251701Medicaid