Provider Demographics
NPI:1760996938
Name:RODRIGUEZ, GWENDOLYN (CRANIAL PROSTHETIC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:CRANIAL PROSTHETIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 CIRCLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-1604
Mailing Address - Country:US
Mailing Address - Phone:804-325-0096
Mailing Address - Fax:
Practice Address - Street 1:808 CIRCLEWOOD DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-1604
Practice Address - Country:US
Practice Address - Phone:804-325-0096
Practice Address - Fax:804-325-0096
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22RO00331168332BC3200X
VA1204017518332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720185762Medicaid