Provider Demographics
NPI:1679976682
Name:RODRIGUEZ, IDELKA GRISSELLE
Entity Type:Individual
Prefix:
First Name:IDELKA
Middle Name:GRISSELLE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IDELKA
Other - Middle Name:GRISELLE
Other - Last Name:RODRIGUEZ-ROSARIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2300 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-5072
Mailing Address - Country:US
Mailing Address - Phone:718-809-1900
Mailing Address - Fax:718-409-8031
Practice Address - Street 1:2300 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5072
Practice Address - Country:US
Practice Address - Phone:718-809-1900
Practice Address - Fax:718-409-8031
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277621207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine