Healthcare Provider Details

I. General information

NPI: 1750988663
Provider Name (Legal Business Name): OSCAR IVAN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2020
Last Update Date: 10/04/2020
Certification Date: 10/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11214 126TH AVENUE CT E APT 3
PUYALLUP WA
98374-2332
US

IV. Provider business mailing address

11214 126TH AVENUE CT E APT 3
PUYALLUP WA
98374-2332
US

V. Phone/Fax

Practice location:
  • Phone: 253-254-9158
  • Fax:
Mailing address:
  • Phone: 253-254-9158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC13730
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: