Provider Demographics
NPI:1710951249
Name:SAMODAL, RODRIGO T (MD)
Entity Type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:T
Last Name:SAMODAL
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 1:2000 PERIMETER PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-8442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 HEALTHPARK WAY STE 100
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-4497
Practice Address - Country:US
Practice Address - Phone:919-585-8850
Practice Address - Fax:919-585-8869
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233438-1207Q00000X
PAMD424079207Q00000X
NC2017-00368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NYP00179402OtherRR MEDICARE PIN
PACC9269OtherRR MEDICARE GROUP
NY02581473Medicaid
PA1011007100001Medicaid
PAP00405510OtherRR MEDICARE PIN
PAGU039851OtherPA MEDICARE GROUP
NYCC8362OtherRR MEDICARE GROUP
NYP00179402OtherRR MEDICARE PIN
PAGU039851OtherPA MEDICARE GROUP