Provider Demographics
NPI:1497992127
Name:GRIGORIY RODONAIA MD PA
Entity Type:Organization
Organization Name:GRIGORIY RODONAIA MD PA
Other - Org Name:RODONAIA FAMILY MEDICINE AND AESTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORIY
Authorized Official - Middle Name:T
Authorized Official - Last Name:RODONAIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-923-1617
Mailing Address - Street 1:2955 HARRISON ST
Mailing Address - Street 2:STE 200
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1154
Mailing Address - Country:US
Mailing Address - Phone:409-923-1617
Mailing Address - Fax:409-923-1618
Practice Address - Street 1:2955 HARRISON ST
Practice Address - Street 2:STE 200
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1154
Practice Address - Country:US
Practice Address - Phone:409-923-1617
Practice Address - Fax:409-923-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM6986261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0048SAOtherBCBS
TX0048SAOtherBCBS