Basic Information
| Provider Information | |||||||||
| NPI: | 1083683023 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODDY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 NE 139TH ST | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604872727 | ||||||||
| FaxNumber: | 3604872729 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 NE 139TH ST. | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604872727 | ||||||||
| FaxNumber: | 3604872729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/14/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD14358 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1027978 | 05 | WA | MEDICAID | 136242 | 05 | OR | MEDICAID |