Provider Demographics
NPI:1417906991
Name:ALTHOFF, RODGER W (MD)
Entity Type:Individual
Prefix:
First Name:RODGER
Middle Name:W
Last Name:ALTHOFF
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 1:1211 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2562
Mailing Address - Country:US
Mailing Address - Phone:360-299-1300
Mailing Address - Fax:
Practice Address - Street 1:1211 24TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221
Practice Address - Country:US
Practice Address - Phone:360-299-5142
Practice Address - Fax:360-299-2043
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421172208600000X
WAAA8830778208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016483700003Medicaid
1530903OtherGATEWAY
548253OtherBCBS
PA0016483700003Medicaid
A14946Medicare UPIN