Provider Demographics
NPI:1275505919
Name:RODOS, MYRON (DO)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:
Last Name:RODOS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 STENTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-3710
Mailing Address - Country:US
Mailing Address - Phone:215-763-9564
Mailing Address - Fax:215-763-1165
Practice Address - Street 1:703 CECIL B MOORE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-2901
Practice Address - Country:US
Practice Address - Phone:215-763-9564
Practice Address - Fax:215-763-1165
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S002454L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006407060008Medicaid
E79093Medicare UPIN
0000041759Medicare ID - Type Unspecified