Provider Demographics
NPI:1689666836
Name:RODRIGUEZ, GUILLERMO L (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:L
Last Name:RODRIGUEZ
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 1:141 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-5852
Mailing Address - Country:US
Mailing Address - Phone:570-454-0500
Mailing Address - Fax:
Practice Address - Street 1:175 S WILKES BARRE BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5040
Practice Address - Country:US
Practice Address - Phone:570-829-2621
Practice Address - Fax:570-823-4332
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD060768L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF80478Medicare UPIN
PA769758Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER