Provider Demographics
NPI:1144780594
Name:RODRIGUEZ, OLAF (MD)
Entity type:Individual
Prefix:DR
First Name:OLAF
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W KENYON RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 W KENYON RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-1004
Practice Address - Country:US
Practice Address - Phone:217-819-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036171478207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology