Healthcare Provider Details

I. General information

NPI: 1225665003
Provider Name (Legal Business Name): CHRISTIAN BO RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 03/15/2023
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COMMUNITY DRIVE EMERGENCY MEDICINE- RESIDENT DIVISION
MANHASSET NY
11030-3816
US

IV. Provider business mailing address

300 COMMUNITY DRIVE DEPARTMENT OF EM, ADMIN SUICE C, ATTN: ELNORA BREVARD
MANHASSET NY
11030-3816
US

V. Phone/Fax

Practice location:
  • Phone: 929-359-2653
  • Fax:
Mailing address:
  • Phone: 929-359-2653
  • Fax:

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 Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME160727
License Number StateFL

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: