Provider Demographics
NPI:1134116700
Name:ROEDER, BRETT (DPM)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:ROEDER
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 1:1501 N GILBERT RD STE 120
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2393
Mailing Address - Country:US
Mailing Address - Phone:480-507-7560
Mailing Address - Fax:480-507-7509
Practice Address - Street 1:1501 N GILBERT RD STE 120
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2393
Practice Address - Country:US
Practice Address - Phone:480-507-7560
Practice Address - Fax:480-507-7509
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0497213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1231210001Medicaid
AZ919110Medicaid
AZAZ0195600OtherBLUE CROSS BLUE SHIELD
Z120957Medicare PIN
U86357Medicare UPIN
AZ1231210001Medicaid
AZZ122589Medicare PIN