Provider Demographics
NPI:1013361179
Name:RODRIGUEZ, JOSE DE JESUS (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:DE JESUS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:DE JESUS
Other - Last Name:RODRIGUEZ LANE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13118 WINDBREAK RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-1821
Mailing Address - Country:US
Mailing Address - Phone:443-758-5271
Mailing Address - Fax:
Practice Address - Street 1:3023 BUNKER HILL ST STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5706
Practice Address - Country:US
Practice Address - Phone:858-483-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA178413208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery