Provider Demographics
NPI:1093376907
Name:MUNGUIA RODRIGUEZ, GERARDO (BD, MSD, CAGS)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:MUNGUIA RODRIGUEZ
Suffix:
Gender:M
Credentials:BD, MSD, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 MADISON ST # 101
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-2108
Mailing Address - Country:US
Mailing Address - Phone:551-208-3497
Mailing Address - Fax:
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:073-972-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ01638174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator