Provider Demographics
NPI:1972590487
Name:ESTRADA, RODEGELIO C (MD)
Entity type:Individual
Prefix:
First Name:RODEGELIO
Middle Name:C
Last Name:ESTRADA
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 1:83 SOUTH ST
Mailing Address - Street 2:STE 4
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1660
Mailing Address - Country:US
Mailing Address - Phone:413-967-5588
Mailing Address - Fax:413-967-3166
Practice Address - Street 1:83 SOUTH ST
Practice Address - Street 2:STE 4
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1660
Practice Address - Country:US
Practice Address - Phone:413-967-5588
Practice Address - Fax:413-967-3166
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA44191207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0101079Medicaid
MAB05040OtherBLUE CROSS AND BLUE SHIEL
MAB05040Medicare PIN
MA0101079Medicaid