Provider Demographics
NPI:1275067803
Name:RODRIGUEZ, JAVIER ENRIQUE
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:ENRIQUE
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAVIER
Other - Middle Name:ENRIQUE
Other - Last Name:RODRIGUEZ DE JESUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 STATE ST APT 205
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA11263800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program