Provider Demographics
NPI:1215011176
Name:RODDAN, RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:
Last Name:RODDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-4135
Mailing Address - Country:US
Mailing Address - Phone:920-496-6000
Mailing Address - Fax:920-496-0998
Practice Address - Street 1:1075 BROOKWOOD DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-4135
Practice Address - Country:US
Practice Address - Phone:920-496-6000
Practice Address - Fax:920-496-0998
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38755600Medicaid
WI38755600Medicaid
WI00037562Medicare ID - Type Unspecified