Healthcare Provider Details

I. General information

NPI: 1467480319
Provider Name (Legal Business Name): SEGUNDO RAMON RODRIGUEZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 E HUNTING PARK AVE SUITE 201
PHILADELPHIA PA
19124-4800
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 215-537-7695
  • Fax: 215-537-7001
Mailing address:
  • Phone: 215-599-4851
  • Fax: 215-232-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSCOO4650L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: