Provider Demographics
NPI:1609265578
Name:RETTIG, RODERIC (ARNP)
Entity Type:Individual
Prefix:
First Name:RODERIC
Middle Name:
Last Name:RETTIG
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N FEDERAL HWY, #301
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-4824
Mailing Address - Country:US
Mailing Address - Phone:954-533-1520
Mailing Address - Fax:
Practice Address - Street 1:2500 N FEDERAL HWY
Practice Address - Street 2:STE 301
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305-1618
Practice Address - Country:US
Practice Address - Phone:954-533-1520
Practice Address - Fax:954-368-5195
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9270207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015607300Medicaid
FL015607300Medicaid