Provider Demographics
NPI:1245459114
Name:ALCANTARA, RODIL DEANG
Entity type:Individual
Prefix:
First Name:RODIL
Middle Name:DEANG
Last Name:ALCANTARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 NE 178TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-3538
Mailing Address - Country:US
Mailing Address - Phone:206-361-2645
Mailing Address - Fax:206-361-2645
Practice Address - Street 1:239 NE 178TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-3538
Practice Address - Country:US
Practice Address - Phone:206-361-2645
Practice Address - Fax:206-361-2645
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9057795Medicaid