Provider Demographics
NPI:1144360835
Name:ROEDER, RYAN (DC)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ROEDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 HAMPTON HALL LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302-3109
Mailing Address - Country:US
Mailing Address - Phone:713-823-1465
Mailing Address - Fax:
Practice Address - Street 1:11133 INTERSTATE 45 S STE 120
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302-5839
Practice Address - Country:US
Practice Address - Phone:936-944-0988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7050111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J0610OtherBLUE CROSS BLUE SHIELD ID
TX9973941OtherCIGNA
TX1030120OtherAMERICAN SPECIALTY HEALTH
TX607547OtherACN PROVIDER ID
TX607547OtherACN PROVIDER ID
TX8J0610OtherBLUE CROSS BLUE SHIELD ID