Provider Demographics
NPI:1942620927
Name:RODRIGUEZ, DIANA MINERVA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MINERVA
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 1:435 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-2101
Mailing Address - Country:US
Mailing Address - Phone:860-224-5661
Mailing Address - Fax:860-224-5785
Practice Address - Street 1:445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1646
Practice Address - Country:US
Practice Address - Phone:860-696-2240
Practice Address - Fax:860-561-7272
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT60074207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program