Basic Information
| Provider Information | |||||||||
| NPI: | 1538835111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ LOPEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | MIGUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | EXT VILLA MARINA | ||||||||
| Address2: | C54 CALLE 4 | ||||||||
| City: | GURABO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007782218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879304415 | ||||||||
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| Practice Location | |||||||||
| Address1: | BO MONACILLOS 150 AVE AMERICO MIRANDA | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009351811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877634149 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2021 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 15937-I | PR | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.