Basic Information
Provider Information | |||||||||
NPI: | 1659952737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RODRIGUES | ||||||||
FirstName: | ANDRE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 411 MCGUIGAN PL | ||||||||
Address2: |   | ||||||||
City: | HARRISON | ||||||||
State: | NJ | ||||||||
PostalCode: | 070292026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735703791 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 375 MCCARTER HWY | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071142562 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9736438601 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2021 | ||||||||
LastUpdateDate: | 04/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA02000900 | NJ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.