Provider Demographics
NPI:1962682419
Name:RODRIGUEZ, MILTON R
Entity Type:Individual
Prefix:
First Name:MILTON
Middle Name:R
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5750
Mailing Address - Country:US
Mailing Address - Phone:215-925-8099
Mailing Address - Fax:215-592-0295
Practice Address - Street 1:256 S 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5750
Practice Address - Country:US
Practice Address - Phone:215-925-8099
Practice Address - Fax:215-592-0295
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01962034Medicaid
PA01962034Medicaid