Basic Information
| Provider Information | |||||||||
| NPI: | 1679840862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAS RODRIGUEZ | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | FERNANDO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 AVE. PONCE DE LEON | ||||||||
| Address2: | APT. 1125 COND. LA CIUDADELA | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7873077854 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | HIMA SAN PABLO CAGUAS | ||||||||
| Address2: | 100 AVE LUIS MUNOZ MARIN | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | R0073 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 390200000X | 13049I | PR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2081P0301X | 19640 | PR | Y |
ID Information
| ID | Type | State | Issuer | Description | 8GA512 | 01 | BCBS | OTHER | 512902YKY3 | 01 | TX | MEDICARE | OTHER |