Provider Demographics
NPI:1467009746
Name:RODRIGUEZ, LUZBERTO
Entity Type:Individual
Prefix:
First Name:LUZBERTO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 CAROLINA PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5629
Mailing Address - Country:US
Mailing Address - Phone:219-689-2681
Mailing Address - Fax:
Practice Address - Street 1:101 W 87TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6177
Practice Address - Country:US
Practice Address - Phone:219-756-0744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160003862225200000X
IN06002840A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN06002840AOtherPTA LICENSE
IL160003862OtherPTA LICENSE