Healthcare Provider Details

I. General information

NPI: 1801007000
Provider Name (Legal Business Name): LEONARDO RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 E BABBITT LN
SAN LUIS AZ
85349
US

IV. Provider business mailing address

PO BOX 1669
SAN LUIS AZ
85349-1669
US

V. Phone/Fax

Practice location:
  • Phone: 928-722-6112
  • Fax: 928-722-6113
Mailing address:
  • Phone: 928-722-6112
  • Fax: 928-722-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME98691
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52439
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: