Healthcare Provider Details

I. General information

NPI: 1407921760
Provider Name (Legal Business Name): RAFAEL RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMB SUITE 145 AVE. 90 RIO HONDO
BAYAMON PR
00961-3113
US

IV. Provider business mailing address

110 ESMERALDA CIELO DORADO VILLAGE
VEGA ALTA PR
00692
US

V. Phone/Fax

Practice location:
  • Phone: 787-378-1040
  • Fax:
Mailing address:
  • Phone: 787-270-1506
  • Fax: 787-870-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number08088
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: