Provider Demographics
NPI:1417036096
Name:ROODE, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:ROODE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 WEST AVE S
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4783
Mailing Address - Country:US
Mailing Address - Phone:608-392-4156
Mailing Address - Fax:608-392-9898
Practice Address - Street 1:310 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2170
Practice Address - Country:US
Practice Address - Phone:608-269-1770
Practice Address - Fax:608-269-1017
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31730208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31683800Medicaid
WI31683800Medicaid