Provider Demographics
NPI:1811461122
Name:RODDY, MARY S
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:RODDY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:DEBOTTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:159 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2045
Mailing Address - Country:US
Mailing Address - Phone:315-342-9575
Mailing Address - Fax:
Practice Address - Street 1:159 WEST FIRST STREET
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1276354181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist