Healthcare Provider Details

I. General information

NPI: 1487574786
Provider Name (Legal Business Name): OMAR JAVIER RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 AVE MUNOZ RIVERA LOCAL 4 VILLA GRILLASCA
PONCE PR
00717
US

IV. Provider business mailing address

KK 32 CALLE 38 URB JARDINES DEL CARIBE
PONCE PR
00728
US

V. Phone/Fax

Practice location:
  • Phone: 939-384-4378
  • Fax:
Mailing address:
  • Phone: 787-667-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1340
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: