Healthcare Provider Details

I. General information

NPI: 1194856377
Provider Name (Legal Business Name): CRISTOBAL RODRIGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 AVE PONCE DE LEON MCS PLAZA PMB#154 SUITE 75
SAN JUAN PR
00917-1919
US

IV. Provider business mailing address

PALACIOS DEL RIO II BLANCO ST. I-2 BOX 664
TOA ALTA PR
00953
US

V. Phone/Fax

Practice location:
  • Phone: 787-758-2500
  • Fax:
Mailing address:
  • Phone: 787-999-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15137
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: