Provider Demographics
NPI:1386717254
Name:SNOW, RODERICK (MD)
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:SNOW
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:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-1280
Mailing Address - Country:US
Mailing Address - Phone:510-964-0458
Mailing Address - Fax:510-964-0476
Practice Address - Street 1:845 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4851
Practice Address - Country:US
Practice Address - Phone:510-964-0458
Practice Address - Fax:510-964-0476
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21192207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A211920Medicaid
CA00A211920Medicaid
CA00A211922Medicare PIN
CA00A211920Medicare ID - Type Unspecified
CA00A211921Medicare PIN