Provider Demographics
NPI:1497753545
Name:MALISOS, RODNEY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:JAMES
Last Name:MALISOS
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 1:1504 NE 96TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1348
Mailing Address - Country:US
Mailing Address - Phone:816-415-2233
Mailing Address - Fax:816-415-2218
Practice Address - Street 1:1504 NE 96TH ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1348
Practice Address - Country:US
Practice Address - Phone:816-415-2233
Practice Address - Fax:816-415-2218
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2011-01-25
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MO2000146367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205388101Medicaid
30006033OtherBLUE CROSS BLUE SHIELD
33106180464024A002OtherTRIWEST
30006033OtherBLUE CROSS BLUE SHIELD
P46B259Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
P00039936Medicare ID - Type UnspecifiedRAILROAD MEDICARE
33106180464024A002OtherTRIWEST