Basic Information
| Provider Information | |||||||||
| NPI: | 1598986127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODERICK | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | BOYD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28374 COUNTY ROAD 317 | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812119158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193959048 | ||||||||
| FaxNumber: | 7193959064 | ||||||||
| Practice Location | |||||||||
| Address1: | 28374 COUNTY ROAD 317 | ||||||||
| Address2: | |||||||||
| City: | BUENA VISTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193959048 | ||||||||
| FaxNumber: | 7193959064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 02/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 6551 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 59269 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100088530B | 05 | KS | MEDICAID |