Provider Demographics
NPI:1710484241
Name:MAZA RODAS, GABINO MANUEL MARIANO (MD)
Entity Type:Individual
Prefix:
First Name:GABINO
Middle Name:MANUEL MARIANO
Last Name:MAZA RODAS
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 1:749 UNIVERSITY ROW STE 200
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-1465
Mailing Address - Country:US
Mailing Address - Phone:708-783-3400
Mailing Address - Fax:708-783-3341
Practice Address - Street 1:1685 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2281
Practice Address - Country:US
Practice Address - Phone:608-265-7593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072445390200000X
WI75118-20207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program