Provider Demographics
NPI:1588789150
Name:GOTTULA, RODERIC DEAN (MD)
Entity type:Individual
Prefix:DR
First Name:RODERIC
Middle Name:DEAN
Last Name:GOTTULA
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 1:800 KENYON RD STE Q
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5776
Mailing Address - Country:US
Mailing Address - Phone:515-574-8519
Mailing Address - Fax:515-574-8514
Practice Address - Street 1:800 KENYON RD STE Q
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5776
Practice Address - Country:US
Practice Address - Phone:515-574-8519
Practice Address - Fax:515-574-8514
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29988207Q00000X
IA44546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO29988OtherSTATE LICENSE
CO804363Medicare ID - Type Unspecified
COD52722Medicare UPIN