Provider Demographics
NPI:1568778371
Name:RODRIGUEZ ALFONSO, JUAN CARLO (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLO
Last Name:RODRIGUEZ ALFONSO
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 1:2000 MEDICAL PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3742
Mailing Address - Country:US
Mailing Address - Phone:410-295-8900
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:STE 101
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:410-295-8900
Practice Address - Fax:443-481-6515
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01086208100000X
MDD79294208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2113Medicaid
NC1568778371Medicaid
NCNCI860AMedicare PIN
P01766251Medicare PIN
SCNC2113Medicaid