Provider Demographics
NPI:1558837021
Name:RODRIGUEZ, GUSTAVO
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
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 1:510 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1564
Mailing Address - Country:US
Mailing Address - Phone:509-865-0800
Mailing Address - Fax:509-865-2904
Practice Address - Street 1:510 W 1ST AVE UNIT 934
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1564
Practice Address - Country:US
Practice Address - Phone:509-865-0800
Practice Address - Fax:509-865-2904
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60900411152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist