Provider Demographics
NPI:1740704683
Name:RODRIGUEZ, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RODRIGUEZ
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 1:2002 SAN BERNARDO AVE
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78040-3142
Mailing Address - Country:US
Mailing Address - Phone:956-225-4047
Mailing Address - Fax:956-273-7394
Practice Address - Street 1:2002 SAN BERNARDO AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-3142
Practice Address - Country:US
Practice Address - Phone:956-225-4047
Practice Address - Fax:956-272-9374
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
22OtherRESPIRATORY, REHABILITATIVE, RESTORATIVE SERVICE PROVIDERS