Provider Demographics
NPI:1003820168
Name:RODRIGUEZ, JAIME (OD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S AIRPORT DR
Mailing Address - Street 2:STE. H
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-5395
Mailing Address - Country:US
Mailing Address - Phone:956-447-2020
Mailing Address - Fax:956-969-0459
Practice Address - Street 1:415 S AIRPORT DR
Practice Address - Street 2:STE. H
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-5395
Practice Address - Country:US
Practice Address - Phone:956-447-2020
Practice Address - Fax:956-969-0459
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5749TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0306300-01Medicaid
TX00E70ZOtherBLUE CROSS BLUE SHIELD
TX6367440001Medicare NSC
00569EMedicare PIN
TXU75498Medicare UPIN
TX00569EMedicare ID - Type Unspecified
TX6367440002Medicare NSC