Provider Demographics
NPI:1720319379
Name:RODOLFO L. RODRIGUEZ, O.D., P.A.
Entity type:Organization
Organization Name:RODOLFO L. RODRIGUEZ, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:LAZARO
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-295-2020
Mailing Address - Street 1:7922 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4175
Mailing Address - Country:US
Mailing Address - Phone:201-295-2020
Mailing Address - Fax:201-295-0804
Practice Address - Street 1:7922 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4175
Practice Address - Country:US
Practice Address - Phone:201-295-2020
Practice Address - Fax:201-295-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00424200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1295900Medicaid
NJT81536Medicare UPIN
NJ1295900Medicaid
NJ521420Medicare PIN