=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467471821
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICARDO E RODRIGUEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2006
-----------------------------------------------------
Last Update Date | 12/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 318 E WESTFIELD AVE
-----------------------------------------------------
City | ROSELLE PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07204-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-245-2229
-----------------------------------------------------
Fax | 908-245-2384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 318 E WESTFIELD AVE
-----------------------------------------------------
City | ROSELLE PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07204-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-245-2229
-----------------------------------------------------
Fax | 908-245-2384
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA52970
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 25MA05297000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------