Provider Demographics
NPI:1184676058
Name:RODRIGUEZ, JESSE STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:STEVEN
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76540-0938
Mailing Address - Country:US
Mailing Address - Phone:254-245-9045
Mailing Address - Fax:
Practice Address - Street 1:135 BUNTON CREEK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5787
Practice Address - Country:US
Practice Address - Phone:512-268-2068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7384207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB152460OtherPTAN
TX031467620Medicaid
TX8B8901Medicare PIN
TX031467620Medicaid
TXP00306044Medicare PIN
TXP00206896Medicare PIN
TX8B7129Medicare PIN
TX8G1374Medicare PIN
TX8D9550Medicare PIN
TX8F1932Medicare PIN
TX8G4271Medicare PIN
TXP00253934Medicare PIN
TXTXB152460OtherPTAN
TXP00147376Medicare PIN