Basic Information
| Provider Information | |||||||||
| NPI: | 1215997036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 BRASS CASTLE RD | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078824327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088351910 | ||||||||
| FaxNumber: | 9088351886 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 MEMORIAL PKWY | ||||||||
| Address2: | SUITE 115 | ||||||||
| City: | PHILLIPSBURG | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088652748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9084543737 | ||||||||
| FaxNumber: | 9084540402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA52001 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4981600 | 05 | NJ | MEDICAID |