Provider Demographics
NPI:1861783185
Name:RODRIGUEZ-RIVERA, ILDEFONSO ISMAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ILDEFONSO
Middle Name:ISMAEL
Last Name:RODRIGUEZ-RIVERA
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-2987
Practice Address - Street 1:2829 BABCOCK RD STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6011
Practice Address - Country:US
Practice Address - Phone:210-580-9500
Practice Address - Fax:210-568-4397
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10039991207R00000X
NY279093207RH0000X
TXPHYTEMP207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX341471603Medicaid