Provider Demographics
NPI:1346769551
Name:RODRIGUEZLOPEZ, SIMON (ATC)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:RODRIGUEZLOPEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MAITLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-2034
Mailing Address - Country:US
Mailing Address - Phone:973-405-7922
Mailing Address - Fax:
Practice Address - Street 1:1 JETS DR
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1215
Practice Address - Country:US
Practice Address - Phone:973-549-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002445002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25T00244500OtherATHLETIC TRAINER