Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 006885 | AZ |
NPI | 1528356284 |
---|---|
Provider Name | Michael Rodriguez |
First Address | Glendale, AZ 85308-4622 |
Second Address | Glendale, AZ 85308-4622 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2011 |
Last Update Date | 11/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
006885 | AZ DO LICENSE (01) | AZ |
117932 | (05) | AZ |