Healthcare Provider Details

I. General information

NPI: 1659552685
Provider Name (Legal Business Name): RICARDO J RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 GAFFNEY RD
FT WAINWRIGHT AK
99703-5002
US

IV. Provider business mailing address

1060 GAFFNEY RD
FT WAINWRIGHT AK
99703-5002
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-6028
  • Fax: 907-361-4847
Mailing address:
  • Phone: 907-361-5163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number259131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: