MEDICARE: DR. JUAN VITELIO RODRIGUEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZC0006X	Clinical Pathology Physician	T9025	TX

General Provider Information

NPI Number	:	1407242548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN VITELIO RODRIGUEZ MD

Provider Business Mailing Address
First Line	:	12436 N SANDBY GREEN DR
Second Line	:
City	:	MARANA
State	:	AZ
Zip	:	85653-8970
Country	:	US
Telephone Number	:	619-709-4848
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 YORK ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06510-3220
Country	:	US
Telephone Number	:	203-688-4242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2015
Last Update Date	:	03/07/2023

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