Provider Demographics
NPI:1497829865
Name:RODRIGUEZ, FERNANDO O (MD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:O
Last Name:RODRIGUEZ
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 1:564 W 189 ST.
Mailing Address - Street 2:APT. 1
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:564 W 189 ST.
Practice Address - Street 2:APT. 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040
Practice Address - Country:US
Practice Address - Phone:212-795-2992
Practice Address - Fax:212-795-2992
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115372208000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00212675Medicaid
NY00212675Medicaid
NY70110Medicare PIN
NYC07747Medicare UPIN