Provider Demographics
NPI:1861719122
Name:ROEDAN, SOCRATES GUSTAVO (MD)
Entity type:Individual
Prefix:
First Name:SOCRATES
Middle Name:GUSTAVO
Last Name:ROEDAN
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 1:395 FORT WASHINGTON AVE STE 6&9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-6741
Mailing Address - Country:US
Mailing Address - Phone:212-928-1400
Mailing Address - Fax:212-923-5595
Practice Address - Street 1:395 FORT WASHINGTON AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-6741
Practice Address - Country:US
Practice Address - Phone:212-928-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274128207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine