Provider Demographics
NPI:1588717375
Name:ROEDEL, ERIC JOHN (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
Last Name:ROEDEL
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 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:425-249-4822
Practice Address - Fax:877-860-2284
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8447856Medicaid
WAI51391Medicare UPIN
WAG8859601Medicare PIN
WA8447856Medicaid
WAG8871865Medicare PIN
WAG8809531Medicare PIN