Healthcare Provider Details

I. General information

NPI: 1881889194
Provider Name (Legal Business Name): PEDRO RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

IV. Provider business mailing address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-3277
  • Fax: 815-986-1448
Mailing address:
  • Phone: 815-398-3277
  • Fax: 815-986-1448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number16856
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number16856
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036110684
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036110684
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: