Provider Demographics
NPI:1427164045
Name:RODRIGUE, DALE L (OD)
Entity type:Individual
Prefix:PROF
First Name:DALE
Middle Name:L
Last Name:RODRIGUE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330
Mailing Address - Country:US
Mailing Address - Phone:207-623-5099
Mailing Address - Fax:207-623-7124
Practice Address - Street 1:58 STATE STREET
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-623-5099
Practice Address - Fax:207-623-7124
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME690T ADVANCED152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME114510000Medicaid
ME114510000Medicaid
ME703725Medicare ID - Type Unspecified