Provider Demographics
NPI:1467480319
Name:RODRIGUEZ, SEGUNDO RAMON (DPM)
Entity Type:Individual
Prefix:DR
First Name:SEGUNDO
Middle Name:RAMON
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-2908
Mailing Address - Country:US
Mailing Address - Phone:215-599-4851
Mailing Address - Fax:215-232-4093
Practice Address - Street 1:841 E HUNTING PARK AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4800
Practice Address - Country:US
Practice Address - Phone:215-537-7695
Practice Address - Fax:215-537-7001
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASCOO4650L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001801104Medicaid
PA001801104Medicaid