Provider Demographics
NPI:1093913402
Name:RODRIGUEZ, EDGAR OMAR (RDH)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:OMAR
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20290 APRICOT LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9480
Mailing Address - Country:US
Mailing Address - Phone:208-602-7014
Mailing Address - Fax:
Practice Address - Street 1:USS BATAAN LHD-5
Practice Address - Street 2:FPO AE
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:09554-1657
Practice Address - Country:US
Practice Address - Phone:757-445-6344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7920171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider