Healthcare Provider Details

I. General information

NPI: 1730606658
Provider Name (Legal Business Name): JEFFREY RODRIGUEZ IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 09/23/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 SCOTT CIR
JBPHH HI
96853-5399
US

IV. Provider business mailing address

755 SCOTT CIR
HONOLULU HI
96818
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6100
  • Fax:
Mailing address:
  • Phone: 808-449-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: