Provider Demographics
NPI:1821085739
Name:RODRIGUEZ COLON, IVAN RAFAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:RAFAEL
Last Name:RODRIGUEZ COLON
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:PO BOX 1221
Mailing Address - Street 2:
Mailing Address - City:JUNCOS
Mailing Address - State:PR
Mailing Address - Zip Code:00777-1221
Mailing Address - Country:US
Mailing Address - Phone:787-713-6505
Mailing Address - Fax:787-713-6505
Practice Address - Street 1:STREET NUMBER 31
Practice Address - Street 2:LOCAL D 2 JUNCOS PLAZA
Practice Address - City:JUNCOS
Practice Address - State:PR
Practice Address - Zip Code:00777-1221
Practice Address - Country:US
Practice Address - Phone:787-713-6505
Practice Address - Fax:787-713-6505
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15093207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR23210Medicare ID - Type Unspecified# MEDICARE
PRI32698Medicare UPIN