Provider Demographics
NPI:1275623191
Name:WOODRUFF, NATHANIEL ROHDE (MD, PHD, FACC)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:ROHDE
Last Name:WOODRUFF
Suffix:
Gender:M
Credentials:MD, PHD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 CATHERINE LN STE F
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5719
Practice Address - Country:US
Practice Address - Phone:530-477-8358
Practice Address - Fax:530-477-2015
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55840207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0605600421OtherBLUE CROSS BLUE SHIELD MI
MI3423708Medicaid
MI060051722OtherRAILROAD MEDICARE
MI0605600421OtherBLUE CROSS BLUE SHIELD MI
MI3423708Medicaid