Provider Demographics
NPI:1780838961
Name:RODRIGUEZ, BRYN MARI (MD)
Entity Type:Individual
Prefix:
First Name:BRYN
Middle Name:MARI
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 W SKYE CANYON PARK DR STE 160-287
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-6623
Mailing Address - Country:US
Mailing Address - Phone:702-350-1463
Mailing Address - Fax:702-470-1815
Practice Address - Street 1:9759 W. SKYE CANYON PARK DR.
Practice Address - Street 2:SUITE 160-287
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166
Practice Address - Country:US
Practice Address - Phone:702-680-5159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105177207R00000X
NV14006208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1780838961Medicaid