Provider Demographics
NPI:1518443480
Name:RODRIGUEZ, RAYMOND ANTONIO
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ANTONIO
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:CALLE CORAL LOMAS VERDES
Mailing Address - Street 2:V 16
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956
Mailing Address - Country:US
Mailing Address - Phone:787-779-9088
Mailing Address - Fax:
Practice Address - Street 1:CALLE CORAL LOMAS VERDES
Practice Address - Street 2:V 16
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:787-779-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1318332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier