Provider Demographics
NPI:1649256736
Name:RODRIGUEZ, GLORIA A (MD, CEC, FACE)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:A
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD, CEC, FACE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 CALLE ALVERIO
Mailing Address - Street 2:LA MERCED
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-2620
Mailing Address - Country:US
Mailing Address - Phone:787-764-1103
Mailing Address - Fax:787-764-1103
Practice Address - Street 1:33 CALLE MAYAGUEZ
Practice Address - Street 2:PEREZ MORRIS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-4917
Practice Address - Country:US
Practice Address - Phone:787-753-6938
Practice Address - Fax:787-993-1764
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6380174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRAR1541095OtherNARCOTICS LICENCE
PR05559DM0OtherLOCAL NARCOTICS LICENCE
PR6380OtherLICENCE NUMBER
PRE31499Medicare UPIN
PR6380OtherLICENCE NUMBER