Provider Demographics
NPI:1497054142
Name:RODRIGUEZ, ROBERTO (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-2446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 PINE POINT RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-8813
Practice Address - Country:US
Practice Address - Phone:207-883-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA3750225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant