Provider Demographics
NPI:1629293972
Name:RODRIGUEZ, RUBEN (M A)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 N CENTRAL AVE
Mailing Address - Street 2:1603
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1325
Mailing Address - Country:US
Mailing Address - Phone:602-340-9121
Mailing Address - Fax:
Practice Address - Street 1:6000 S 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-4209
Practice Address - Country:US
Practice Address - Phone:602-243-4866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1982724480Medicare ID - Type Unspecified