Provider Demographics
NPI:1205038965
Name:RODABAUGH, TODD T
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:T
Last Name:RODABAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-2443
Mailing Address - Country:US
Mailing Address - Phone:607-739-9121
Mailing Address - Fax:
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-2443
Practice Address - Country:US
Practice Address - Phone:607-739-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005967156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02064217Medicaid
NY0886760001Medicare ID - Type Unspecified