Provider Demographics
NPI:1679851364
Name:RODRIGUEZ, CARLOS ANTONY (IDC)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:ANTONY
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-958 PANANA ST
Mailing Address - Street 2:UNIT 22
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-1329
Mailing Address - Country:US
Mailing Address - Phone:202-361-6286
Mailing Address - Fax:
Practice Address - Street 1:92- 958 PANANA STREET
Practice Address - Street 2:UNIT 22
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-6604
Practice Address - Country:US
Practice Address - Phone:202-361-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman