Provider Demographics
NPI:1811645427
Name:RODRIGUEZ, DERICK
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1. EST DE BEATRIZ
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736
Mailing Address - Country:US
Mailing Address - Phone:939-243-8042
Mailing Address - Fax:939-243-8042
Practice Address - Street 1:1. EST DE BEATRIZ
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:939-243-8042
Practice Address - Fax:939-243-8042
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR17113208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program