Provider Demographics
NPI:1942350947
Name:HUBERT, RODERICK LANDON (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:LANDON
Last Name:HUBERT
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 1:3916 N INTERTECH CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6957
Mailing Address - Country:US
Mailing Address - Phone:920-996-1000
Mailing Address - Fax:920-996-1054
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6957
Practice Address - Country:US
Practice Address - Phone:920-996-1000
Practice Address - Fax:920-996-1054
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22625207R00000X
MI4301089219207R00000X
WI63905-20207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5200096Medicaid
MI0E26038017Medicare PIN