Provider Demographics
NPI:1154835130
Name:RODRIGUEZ OQUENDO, JOSE MIGUEL (SA-C)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:RODRIGUEZ OQUENDO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W BELMONT AVE APT 5M
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6824
Mailing Address - Country:US
Mailing Address - Phone:773-387-2619
Mailing Address - Fax:
Practice Address - Street 1:505 W BELMONT AVE APT 5M
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6824
Practice Address - Country:US
Practice Address - Phone:773-387-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17-394246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant