Provider Demographics
NPI:1598937104
Name:BRUCE A RODAN MD PA
Entity Type:Organization
Organization Name:BRUCE A RODAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:RODAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-575-7123
Mailing Address - Street 1:111 WATERBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7743
Mailing Address - Country:US
Mailing Address - Phone:561-575-7123
Mailing Address - Fax:561-745-7440
Practice Address - Street 1:111 WATERBRIDGE LN
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7743
Practice Address - Country:US
Practice Address - Phone:561-575-7123
Practice Address - Fax:561-745-7440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0378782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045954200Medicaid
FLD65258Medicare UPIN
FL045954200Medicaid