Provider Demographics
NPI:1518137306
Name:RODRIGUEZ, CARLOS FREDERICO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:FREDERICO
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:830 AINSWORTH DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1630
Practice Address - Country:US
Practice Address - Phone:928-777-5800
Practice Address - Fax:928-776-0405
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119039207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
AZ42919207N00000X, 207ND0101X, 207NI0002X, 207NP0225X, 207NS0135X, 207ZD0900X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ867831Medicaid
AZ9735166OtherAETNA
AZP01291608OtherRAILROAD MCR
AZ867831Medicaid
AZ9735166OtherAETNA