Provider Demographics
NPI:1962607317
Name:HARTMAN, RODERIC JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:RODERIC
Middle Name:JOEL
Last Name:HARTMAN
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 1669
Mailing Address - Street 2:1896 E BABBITT LANE
Mailing Address - City:SAN LUIS
Mailing Address - State:AZ
Mailing Address - Zip Code:85349-1669
Mailing Address - Country:US
Mailing Address - Phone:928-722-6112
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1896 E BABBITT LANE
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-1669
Practice Address - Country:US
Practice Address - Phone:928-722-6112
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87523208000000X
AZ21315208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ651170616OtherTAX ID
AZ907349Medicaid
AZZ166885Medicare UPIN
AZ651170616OtherTAX ID