Provider Demographics
NPI:1528082450
Name:RODRIGUEZ, RICK (OD)
Entity type:Individual
Prefix:DR
First Name:RICK
Middle Name:
Last Name:RODRIGUEZ
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:PO BOX 31817
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-0817
Mailing Address - Country:US
Mailing Address - Phone:314-664-1158
Mailing Address - Fax:314-664-0837
Practice Address - Street 1:3535 S JEFFERSON AVE
Practice Address - Street 2:SUITE S7
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-664-1158
Practice Address - Fax:314-664-0837
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03057152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24551Medicare ID - Type UnspecifiedIL MEDICARE
MOU42425Medicare UPIN