Provider Demographics
NPI:1477948420
Name:FISETTE, RODERICK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:JOHN
Last Name:FISETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RODERICK
Other - Middle Name:JOHN
Other - Last Name:FISETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 296
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-0296
Mailing Address - Country:US
Mailing Address - Phone:409-221-1500
Mailing Address - Fax:
Practice Address - Street 1:1200 TURNER DR
Practice Address - Street 2:
Practice Address - City:BRIDGE CITY
Practice Address - State:TX
Practice Address - Zip Code:77611-2612
Practice Address - Country:US
Practice Address - Phone:409-221-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD6746208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice