Provider Demographics
NPI:1821070996
Name:RODRIGUEZ, EDWIN IVAN (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:IVAN
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2800 SW WANAMAKER RD
Mailing Address - Street 2:SUITE 192
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-4293
Mailing Address - Country:US
Mailing Address - Phone:785-272-0707
Mailing Address - Fax:785-271-1512
Practice Address - Street 1:15311 W 119TH ST
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-5290
Practice Address - Country:US
Practice Address - Phone:913-780-3200
Practice Address - Fax:913-780-6770
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS-1466152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22515081OtherBCBS OF KC
KS100220540BMedicaid
KS3405670OtherAETNA
390312OtherBCBS
KSP00327881OtherMEDICARE RAILROAD
KSL31E608Medicare PIN
KSP00327881OtherMEDICARE RAILROAD