Provider Demographics
NPI:1477589414
Name:BERDECIA-RODRIGUEZ, JOSEPH (MD-PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:BERDECIA-RODRIGUEZ
Suffix:
Gender:M
Credentials:MD-PHD
Other - Prefix:DR
Other - First Name:JOSEPH
Other - Middle Name:
Other - Last Name:BERDECIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD-PHD
Mailing Address - Street 1:151 PALM CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072
Mailing Address - Country:US
Mailing Address - Phone:406-470-6920
Mailing Address - Fax:
Practice Address - Street 1:512 SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3787
Practice Address - Country:US
Practice Address - Phone:218-879-4641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA28260207Q00000X
MT34357207Q00000X
MN54017207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI13273OtherPIN
IAE97416Medicare UPIN