Provider Demographics
NPI:1750494340
Name:PRODOEHL, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:PRODOEHL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:421 S. UNION AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HAVRE DE GRACE
Mailing Address - State:MD
Mailing Address - Zip Code:21078
Mailing Address - Country:US
Mailing Address - Phone:410-939-7077
Mailing Address - Fax:410-939-7983
Practice Address - Street 1:619 CANAL ST STE 110
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6982
Practice Address - Country:US
Practice Address - Phone:386-734-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME162392207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD463362OtherALLIANCE
MD20-0272326OtherFEDERAL TAX ID
MDJ270OtherCAREFIRST BLUE CHOICE
MD120096600OtherUS DEPARTMENT OF LABOR
MD610761-01OtherCAREFIRST POINT OF SERVIC
MDDB2566OtherRAILROAD MEDICARE
MD011621OtherPRIORITY PARTNERS
MD5678388OtherAETNA PROVIDER NUMBER
MDDB2566OtherRAILROAD MEDICARE
MDG30383Medicare UPIN