Healthcare Provider Details

I. General information

NPI: 1477273449
Provider Name (Legal Business Name): MARIA C RODRIGUEZ OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7153 CERMAK RD
BERWYN IL
60402-2134
US

IV. Provider business mailing address

1507 OAK PARK AVE
BERWYN IL
60402-1340
US

V. Phone/Fax

Practice location:
  • Phone: 708-795-8585
  • Fax:
Mailing address:
  • Phone: 773-600-1443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011685
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number046011685
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046011685
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: