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General NPI Number Information
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NPI Number | 1275056236
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Entity Type | Individual
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Provider Name | JAVIER RAMIRO RODRIGUEZ OD
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Gender | Male
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Dates
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Enumeration Date | 07/21/2017
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 205 N STATE ST
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City | MARENGO
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State | IL
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Zip | 60152-2239
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Country | US
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Telephone | 815-568-6508
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Fax |
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Provider Business Mailing Address
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Address Line | 1591 CARLEMONT DR APT B
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014-2742
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046.011137
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License Number State | IL
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