Provider Demographics
NPI:1801884580
Name:HAITHCOCK, RODERICK ERVIN (MD)
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:ERVIN
Last Name:HAITHCOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W. LEIGH STREET
Mailing Address - Street 2:SUITE 303
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220
Mailing Address - Country:US
Mailing Address - Phone:804-644-1333
Mailing Address - Fax:804-782-1193
Practice Address - Street 1:505 W. LEIGH STREET
Practice Address - Street 2:SUITE 303
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220
Practice Address - Country:US
Practice Address - Phone:804-644-1333
Practice Address - Fax:804-782-1193
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029287207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6078460Medicaid
VAC06695OtherGROUP PTAN
VA6078460Medicaid
VA112950757Medicare PIN