Provider Demographics
NPI:1891102620
Name:RODULFA, JASON BALTAR (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:BALTAR
Last Name:RODULFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6300
Practice Address - Fax:208-625-6301
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-173372085N0700X, 2085R0202X
WV300162085N0700X, 2085R0202X
NV202932085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty