Provider Demographics
NPI:1609859156
Name:RODOSTA, FREDERICK G (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:G
Last Name:RODOSTA
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 1:305 E PRUDHOMME ST
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-6490
Mailing Address - Country:US
Mailing Address - Phone:337-948-6511
Mailing Address - Fax:337-948-6512
Practice Address - Street 1:305 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6490
Practice Address - Country:US
Practice Address - Phone:337-948-6511
Practice Address - Fax:337-948-6512
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010172208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0632240001OtherDURABLE MEDICAL EQUIPMENT
LA1112071Medicaid
LA342009015OtherRAILROAD MEDICARE
LA720700403OtherTAX ID
LA720700403OtherTAX ID
LAB89880Medicare UPIN