Provider Demographics
NPI:1871709063
Name:RODENAS, MARIO (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:RODENAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARIO
Other - Middle Name:
Other - Last Name:RODENAS-MEDINA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6 DEVINE ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2222
Mailing Address - Country:US
Mailing Address - Phone:203-287-6200
Mailing Address - Fax:
Practice Address - Street 1:6 DEVINE ST STE 2B
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2222
Practice Address - Country:US
Practice Address - Phone:203-287-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME126080207K00000X, 207R00000X
CT045989207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016920600Medicaid
FL016920600Medicaid