Provider Demographics
NPI:1912479007
Name:RODERIQUES, TIMOTHY PAUL
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PAUL
Last Name:RODERIQUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 OCEAN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3555
Mailing Address - Country:US
Mailing Address - Phone:508-509-0631
Mailing Address - Fax:
Practice Address - Street 1:48 OCEAN ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3555
Practice Address - Country:US
Practice Address - Phone:508-509-0631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS79139087347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle