Provider Demographics
NPI:1184037319
Name:RODRIGUEZ, ROGER (MD)
Entity Type:Individual
Prefix:MR
First Name:ROGER
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 1:626 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1537
Mailing Address - Country:US
Mailing Address - Phone:908-337-3881
Mailing Address - Fax:
Practice Address - Street 1:626 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1537
Practice Address - Country:US
Practice Address - Phone:908-337-3881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-088126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF88253Medicare UPIN