Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | ML60096761 | WA |
NPI | 1003046426 |
---|---|
Provider Name | Mr. John L Rodakowski |
First Address | Elma, WA 98541 |
Second Address | Mcclearly, WA 98557-9522 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2009 |
Last Update Date | 24/01/2013 |