Provider Demographics
NPI:1053536250
Name:RODRIGUEZ, RAFAEL ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ANTONIO
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 1:9224 QUEENS BOULEVARD # 747887
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-7887
Mailing Address - Country:US
Mailing Address - Phone:347-605-2785
Mailing Address - Fax:646-572-8781
Practice Address - Street 1:3711 88TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7630
Practice Address - Country:US
Practice Address - Phone:347-605-2785
Practice Address - Fax:347-572-8781
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179642207L00000X, 207LP2900X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01618015Medicaid
NY02016Medicare ID - Type UnspecifiedPIN GHI MEDICARE
NY01618015Medicaid