Healthcare Provider Details

I. General information

NPI: 1275056236
Provider Name (Legal Business Name): JAVIER RAMIRO RODRIGUEZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N STATE ST
MARENGO IL
60152-2239
US

IV. Provider business mailing address

1591 CARLEMONT DR APT B
CRYSTAL LAKE IL
60014-2742
US

V. Phone/Fax

Practice location:
  • Phone: 815-568-6508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011137
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: