Basic Information
| Provider Information | |||||||||
| NPI: | 1265815179 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODDICK | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 E. ADAMS STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645240 | ||||||||
| FaxNumber: | 3154643751 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 E. ADAMS STREET | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645240 | ||||||||
| FaxNumber: | 3154643751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2015 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.