Provider Demographics
NPI:1760045447
Name:RODERICKS, TYLER (DPM)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:RODERICKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 ASHLAND ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2920
Mailing Address - Country:US
Mailing Address - Phone:408-693-1999
Mailing Address - Fax:
Practice Address - Street 1:12416 66TH ST STE A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-3430
Practice Address - Country:US
Practice Address - Phone:727-547-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPDL1528213ES0103X
FLPO4481390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery