Provider Demographics
NPI:1124739628
Name:RODRIGUEZ MATOS, ANGEL OBRYAN
Entity type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:OBRYAN
Last Name:RODRIGUEZ MATOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB OLIMPIC PARK 110 CALLE ATENAS
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:URB OLIMPIC PARK CALLE ATENAS
Practice Address - Street 2:
Practice Address - City:LAS PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00771
Practice Address - Country:US
Practice Address - Phone:939-273-5787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR012297183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician