Healthcare Provider Details

I. General information

NPI: 1083577944
Provider Name (Legal Business Name): SAM ELI RODRIGUEZ
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 EMMORTON PARK RD STE E
EDGEWOOD MD
21040-1066
US

IV. Provider business mailing address

8365 DISTINCTIVE DR
SAN DIEGO CA
92108-2600
US

V. Phone/Fax

Practice location:
  • Phone: 443-402-1925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34161
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: