Provider Demographics
NPI:1851386155
Name:RODAN, KATHRYN P (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:P
Last Name:RODAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3125
Mailing Address - Country:US
Mailing Address - Phone:510-763-2662
Mailing Address - Fax:510-763-2679
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-763-2662
Practice Address - Fax:510-763-2679
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
CAG53393207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52511Medicare UPIN
CA00G533930Medicare ID - Type Unspecified