Provider Demographics
NPI:1831197649
Name:RODDY, ROBERT J
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:RODDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:STE 120
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-999-0203
Mailing Address - Fax:651-999-0264
Practice Address - Street 1:1690 UNIVERSITY AVE W
Practice Address - Street 2:STE 120
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3723
Practice Address - Country:US
Practice Address - Phone:651-999-0203
Practice Address - Fax:651-999-0264
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-20
Provider Licenses
StateLicense IDTaxonomies
MNMN315802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
C46892Medicare UPIN