Provider Demographics
NPI:1316983125
Name:PEROCHO, RODOLFO R (MD)
Entity type:Individual
Prefix:
First Name:RODOLFO
Middle Name:R
Last Name:PEROCHO
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:1000 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104-1132
Practice Address - Country:US
Practice Address - Phone:856-246-3160
Practice Address - Fax:856-246-3061
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA45770207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3728706Medicaid
NJ553710Medicare ID - Type Unspecified
NJ3728706Medicaid