Provider Demographics
NPI:1164411286
Name:WILMAR C RODRIGUEZ, M.D., PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:WILMAR C RODRIGUEZ, M.D., PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-321-7683
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-0847
Mailing Address - Country:US
Mailing Address - Phone:316-321-7683
Mailing Address - Fax:316-322-7750
Practice Address - Street 1:700 W CENTRAL AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2184
Practice Address - Country:US
Practice Address - Phone:316-321-7683
Practice Address - Fax:316-322-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24390208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSC77408Medicare UPIN
KS014509Medicare ID - Type Unspecified