Provider Demographics
NPI:1548315492
Name:RODRIGUES, MARK (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RODRIGUES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 FERRY ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3220
Mailing Address - Country:US
Mailing Address - Phone:973-589-7772
Mailing Address - Fax:973-589-8228
Practice Address - Street 1:234 FERRY ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3220
Practice Address - Country:US
Practice Address - Phone:973-589-7772
Practice Address - Fax:973-589-8228
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJRO164738Medicare ID - Type Unspecified