Provider Demographics
NPI:1780367524
Name:RODRIGUEZ DE JESUS, EDIBERTO III (AUD)
Entity type:Individual
Prefix:
First Name:EDIBERTO III
Middle Name:
Last Name:RODRIGUEZ DE JESUS
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 7 BOX 17141
Mailing Address - Street 2:
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953-8844
Mailing Address - Country:US
Mailing Address - Phone:787-293-7485
Mailing Address - Fax:
Practice Address - Street 1:HACIENDAD DEL CARIBE
Practice Address - Street 2:CALLE YUQUIYU I-9
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-293-7485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1033231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist