Provider Demographics
NPI:1750391686
Name:RODRIGUEZ-BOSTOCK, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:RODRIGUEZ-BOSTOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S MAIN ST
Mailing Address - Street 2:STE 6
Mailing Address - City:OCEAN GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07756-2017
Mailing Address - Country:US
Mailing Address - Phone:732-987-5780
Mailing Address - Fax:732-987-5787
Practice Address - Street 1:27 S COOKS BRIDGE RD
Practice Address - Street 2:STE 2-1
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2524
Practice Address - Country:US
Practice Address - Phone:732-987-5780
Practice Address - Fax:732-987-5787
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06662300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7963807Medicaid
NJ7963807Medicaid
NJ028108WNCMedicare PIN