Provider Demographics
NPI:1275860603
Name:RODRIGUEZ, MICHAEL J (SUBMARINE IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS KEY WEST #SSN722
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96683-2402
Mailing Address - Country:US
Mailing Address - Phone:808-471-5625
Mailing Address - Fax:808-473-3109
Practice Address - Street 1:822 CLARK ST.
Practice Address - Street 2:NSSC MEDICAL SUITE 400
Practice Address - City:PEARL HARBOR
Practice Address - State:HI
Practice Address - Zip Code:96860
Practice Address - Country:US
Practice Address - Phone:808-473-3771
Practice Address - Fax:808-473-3109
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7383OtherTRICARE