Provider Demographics
NPI:1417998600
Name:RODDY, MARK GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:RODDY
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 1:5906 OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ECHO
Mailing Address - State:MD
Mailing Address - Zip Code:20812-1204
Mailing Address - Country:US
Mailing Address - Phone:301-263-1110
Mailing Address - Fax:
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1483
Practice Address - Country:US
Practice Address - Phone:301-754-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00601752080P0204X
DCMD342092080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH90999Medicare UPIN
DC012511S58Medicare PIN