Provider Demographics
NPI:1881791663
Name:DEJESUS-RODRIGUEZ, REYNALDO (MD)
Entity type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:DEJESUS-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 1:909 AVE TITO CASTRO STE 614
Mailing Address - Street 2:TORRE MEDICA SAN LUCAS
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-840-8174
Mailing Address - Fax:787-843-2084
Practice Address - Street 1:909 AVE TITO CASTRO STE 614
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4722
Practice Address - Country:US
Practice Address - Phone:787-840-8174
Practice Address - Fax:787-843-2084
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13269207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR037693801Medicaid
OR027945Medicaid
2-6300Medicare PIN
I47247Medicare UPIN