Provider Demographics
NPI:1235197765
Name:RODRIGUEZ VALLECILLO, EDGARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGARDO
Middle Name:
Last Name:RODRIGUEZ VALLECILLO
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 1:29 CALLE WASHINGTON
Mailing Address - Street 2:SUITE 507
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1521
Mailing Address - Country:US
Mailing Address - Phone:787-723-7230
Mailing Address - Fax:787-723-2723
Practice Address - Street 1:29 CALLE WASHINGTON
Practice Address - Street 2:SUITE 507
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1521
Practice Address - Country:US
Practice Address - Phone:787-723-7230
Practice Address - Fax:787-723-2723
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2015-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6941207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRC-84229Medicare UPIN