Provider Demographics
NPI:1669122792
Name:RODRIGUEZ IZQUIERDO, EDARIS
Entity type:Individual
Prefix:
First Name:EDARIS
Middle Name:
Last Name:RODRIGUEZ IZQUIERDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 8 BOX 38251
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725-9402
Mailing Address - Country:US
Mailing Address - Phone:787-233-3204
Mailing Address - Fax:
Practice Address - Street 1:1046 AVE HOSTOS STE 118
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-1119
Practice Address - Country:US
Practice Address - Phone:787-841-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
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