Healthcare Provider Details

I. General information

NPI: 1619007689
Provider Name (Legal Business Name): VICTOR J RODRIGUES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/18/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EL PASO RD
RUIDOSO NM
88345-6033
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-630-4230
  • Fax: 575-630-4237
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2008-0658
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2008-0658
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: