Provider Demographics
NPI:1699859405
Name:RODRIGUE, RAY
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:RODRIGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:250 DELAWARE AVE
Practice Address - Street 2:DELMAR URGENT VISIT
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054
Practice Address - Country:US
Practice Address - Phone:518-439-8077
Practice Address - Fax:518-439-8070
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02341046Medicaid
NYS73028Medicare UPIN
NYBB9917Medicare PIN