Provider Demographics
NPI:1528044534
Name:RODRIGUEZ, ELLIOTT (OD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TENIENTE ALVARADO ST
Mailing Address - Street 2:
Mailing Address - City:YAUCO
Mailing Address - State:PR
Mailing Address - Zip Code:00698-3538
Mailing Address - Country:US
Mailing Address - Phone:787-856-8253
Mailing Address - Fax:787-856-3141
Practice Address - Street 1:2 TENIENTE ALVARADO ST
Practice Address - Street 2:
Practice Address - City:YAUCO
Practice Address - State:PR
Practice Address - Zip Code:00698-3538
Practice Address - Country:US
Practice Address - Phone:787-856-8253
Practice Address - Fax:787-856-3141
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR0248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U12425Medicare UPIN
05876Medicare ID - Type Unspecified