Provider Demographics
NPI:1265144463
Name:RODRIGUEZ, RUBEN EDGARDO
Entity type:Individual
Prefix:
First Name:RUBEN
Middle Name:EDGARDO
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 1:1783 CARRETERA 21 VILLA MAGNA PH 04
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921
Mailing Address - Country:US
Mailing Address - Phone:787-328-4872
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 14 INTERIOR BARRIO RINCON
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-535-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program