Provider Demographics
NPI:1134716160
Name:IBARRA RODRIGUEZ, ROGELIO JR
Entity type:Individual
Prefix:
First Name:ROGELIO JR
Middle Name:
Last Name:IBARRA 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 1:1080 MARINA VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3933 HARRISON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3523
Practice Address - Country:US
Practice Address - Phone:833-391-0505
Practice Address - Fax:951-358-7401
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information