Provider Demographics
NPI:1255640694
Name:RODRIGUEZ, JOHANA (OD)
Entity type:Individual
Prefix:MRS
First Name:JOHANA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PLAZA FAJARDO 150 CARR 940
Mailing Address - Street 2:STE 240
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-3678
Mailing Address - Country:US
Mailing Address - Phone:787-863-3580
Mailing Address - Fax:787-860-1333
Practice Address - Street 1:118 AVE DOMENECH
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3503
Practice Address - Country:US
Practice Address - Phone:787-586-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR666-0202152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist