Provider Demographics
NPI:1639688583
Name:RODRIGUEZ REQUENA, JESUS SALVADOR (SA-C525)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:SALVADOR
Last Name:RODRIGUEZ REQUENA
Suffix:
Gender:M
Credentials:SA-C525
Other - Prefix:
Other - First Name:JESUS
Other - Middle Name:SALVADOR
Other - Last Name:RODRIGUEZ REQUENA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FIRST SA
Mailing Address - Street 1:8814 W FLAGLER ST APT 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-3946
Mailing Address - Country:US
Mailing Address - Phone:305-497-3036
Mailing Address - Fax:
Practice Address - Street 1:8814 W FLAGLER ST APT 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-3946
Practice Address - Country:US
Practice Address - Phone:305-497-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR362437644660246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant