Healthcare Provider Details

I. General information

NPI: 1497371314
Provider Name (Legal Business Name): WILSON EDUARDO RODRIGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date: 01/18/2022
Reactivation Date: 02/03/2022

III. Provider practice location address

1008 S. SPRING
ST LOUIS MO
63110
US

IV. Provider business mailing address

1008 S. SPRING
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6082
  • Fax: 314-977-4876
Mailing address:
  • Phone: 314-977-6082
  • Fax: 314-977-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2024009532
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: