Provider Demographics
NPI:1619330966
Name:RODERICKS, DEIRDRE (MD)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:RODERICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-3109
Mailing Address - Country:US
Mailing Address - Phone:617-952-5299
Mailing Address - Fax:
Practice Address - Street 1:159 WELLS AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3301
Practice Address - Country:US
Practice Address - Phone:617-243-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267300207R00000X
IL125069738208100000X
390200000X
MA2901852081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty