Provider Demographics
NPI:1174667281
Name:RODRIGUEZ, EDWIN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10614
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-0614
Mailing Address - Country:US
Mailing Address - Phone:787-259-1654
Mailing Address - Fax:
Practice Address - Street 1:LEGACY OFFICE PARK SUITE102
Practice Address - Street 2:CARR 506, KM 0.75
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-259-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRDM150128208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR21988Medicare ID - Type UnspecifiedMEDICARE EN PR