Basic Information
| Provider Information | |||||||||
| NPI: | 1316915523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PHILIP | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 HALLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117761232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316421190 | ||||||||
| FaxNumber: | 6316421190 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 HALLOCK AVE | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117761232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316421190 | ||||||||
| FaxNumber: | 6316421190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/06/2010 | ||||||||
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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 | 207R00000X | 229069 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 229069 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.