Provider Demographics
NPI:1053411769
Name:COURSON, RODNEY GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:GLEN
Last Name:COURSON
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 1:3880 STOCKTON HILL RD STE 103128
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-0595
Mailing Address - Country:US
Mailing Address - Phone:928-279-1387
Mailing Address - Fax:928-757-7272
Practice Address - Street 1:3880 STOCKTON HILL RD STE 103128
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-0595
Practice Address - Country:US
Practice Address - Phone:928-279-1387
Practice Address - Fax:928-757-7272
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30616208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ726044Medicaid
AZG30026Medicare UPIN
AZ726044Medicaid
AZZ137106Medicare PIN