Healthcare Provider Details

I. General information

NPI: 1093913402
Provider Name (Legal Business Name): EDGAR OMAR RODRIGUEZ RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS BATAAN LHD-5 FPO AE
NORFOLK VA
09554-1657
US

IV. Provider business mailing address

20290 APRICOT LN
CALDWELL ID
83607-9480
US

V. Phone/Fax

Practice location:
  • Phone: 757-445-6344
  • Fax:
Mailing address:
  • Phone: 208-602-7014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number7920
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: