Provider Demographics
NPI:1679923387
Name:RODEFFER, CARSON (MD)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:RODEFFER
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 1:1552 COFFEE RD FL 1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3122
Mailing Address - Country:US
Mailing Address - Phone:095-214-3722
Mailing Address - Fax:095-232-0052
Practice Address - Street 1:1552 COFFEE RD FL 1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3122
Practice Address - Country:US
Practice Address - Phone:209-521-4372
Practice Address - Fax:095-232-0052
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA168432207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology