Provider Demographics
NPI:1346620010
Name:RODRIGUEZ UNDA, NELSON AGUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:AGUSTIN
Last Name:RODRIGUEZ UNDA
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 1:1155 N MAYFAIR RD STE T2600
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3464
Mailing Address - Country:US
Mailing Address - Phone:414-955-1000
Mailing Address - Fax:414-955-0183
Practice Address - Street 1:1155 N MAYFAIR RD STE T2600
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3464
Practice Address - Country:US
Practice Address - Phone:414-955-1000
Practice Address - Fax:414-955-0183
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI764812086S0122X
TXBP100620902086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1346620010Medicaid