Provider Demographics
NPI:1124127634
Name:RODA, FERDINAND TABUCOL (MD)
Entity type:Individual
Prefix:
First Name:FERDINAND
Middle Name:TABUCOL
Last Name:RODA
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 1:1 MERCY LN
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6442
Mailing Address - Country:US
Mailing Address - Phone:501-609-0224
Mailing Address - Fax:501-609-0666
Practice Address - Street 1:1 MERCY LN
Practice Address - Street 2:SUITE 301
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6442
Practice Address - Country:US
Practice Address - Phone:501-609-0224
Practice Address - Fax:501-609-0666
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-4526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR123957001Medicaid
AR13278000001OtherQUALCHOICE
AR5J212OtherBLUE
ARDF5380OtherRAILROAD
ARDF5380OtherRAILROAD
ARC44480Medicare UPIN