Provider Demographics
NPI:1790794600
Name:ROEDER, BRENT E (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:ROEDER
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 1:720 SW LANE ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1539
Mailing Address - Country:US
Mailing Address - Phone:785-270-4800
Mailing Address - Fax:
Practice Address - Street 1:720 SW LANE ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1539
Practice Address - Country:US
Practice Address - Phone:785-270-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-31241207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS067329OtherMEDICARE PTAN
KS200347420AMedicaid
H20489Medicare UPIN