Provider Demographics
NPI:1063836005
Name:RODRIGUEZ GARCIA, GRETTEL
Entity Type:Individual
Prefix:
First Name:GRETTEL
Middle Name:
Last Name:RODRIGUEZ GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WOODSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8396
Mailing Address - Country:US
Mailing Address - Phone:347-342-2441
Mailing Address - Fax:
Practice Address - Street 1:31 WOODSTONE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8396
Practice Address - Country:US
Practice Address - Phone:347-342-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23695207R00000X, 207RB0002X
282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09036365Medicaid
MS403365YKFFMedicare PIN