Provider Demographics
NPI:1336164557
Name:RODRIGUE, BENJAMIN JOHN (O T R)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:JOHN
Last Name:RODRIGUE
Suffix:
Gender:M
Credentials:O T R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 EMBASSY OAKS DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2024
Mailing Address - Country:US
Mailing Address - Phone:210-490-4738
Mailing Address - Fax:210-490-5231
Practice Address - Street 1:415 EMBASSY OAKS DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-2024
Practice Address - Country:US
Practice Address - Phone:210-490-4738
Practice Address - Fax:210-490-5231
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110687225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D0066Medicare ID - Type Unspecified