Healthcare Provider Details

I. General information

NPI: 1164600847
Provider Name (Legal Business Name): FIDEL J RODRIGUEZ CRUZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARRETERA # 3 KM 19.9 EDIFICIO EAST MEDICAL PROFESSIONAL CENTER
CANOVANAS PR
00729
US

IV. Provider business mailing address

PO BOX 1270
CANOVANAS PR
00729-1270
US

V. Phone/Fax

Practice location:
  • Phone: 787-256-6060
  • Fax: 787-256-6061
Mailing address:
  • Phone: 787-256-6060
  • Fax: 787-256-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. FIDEL JOEL RODRIGUEZ
Title or Position: OPTICIAN
Credential:
Phone: 787-256-6060