Basic Information
| Provider Information | |||||||||
| NPI: | 1811921349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | RAMON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY, WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS ROOM 2B-321 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY, WOODHULL MEDICAL & MENTAL HEALTH CENTER | ||||||||
| Address2: | DEPARTMENT OF PEDIATRICS | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638000 | ||||||||
| FaxNumber: | 7186303122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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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 | 177629 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 177629 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01358387 | 05 | NY | MEDICAID |