Provider Demographics
NPI:1750370284
Name:LEON - RODRIGUEZ, JERRY LUIS (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LUIS
Last Name:LEON - RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COSTA CARIBE RESORT
Mailing Address - Street 2:1253 DON QUIJOTE ST.
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-675-7706
Mailing Address - Fax:787-844-7706
Practice Address - Street 1:CONDOMINIO SAN VICENTE STE 211
Practice Address - Street 2:8169 CALLE CONCORDIA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1564
Practice Address - Country:US
Practice Address - Phone:787-843-5420
Practice Address - Fax:787-848-5287
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13986174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist