Provider Demographics
NPI:1255306684
Name:ROODMAN, GARSON DAVID (MD,PHD)
Entity Type:Individual
Prefix:DR
First Name:GARSON
Middle Name:DAVID
Last Name:ROODMAN
Suffix:
Gender:M
Credentials:MD,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073272L174400000X
IN01070545A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001843230Medicaid
IN201045180Medicaid
PA001843230Medicaid
PAC21269Medicare UPIN