Provider Demographics
NPI:1225765233
Name:RODRIGUEZ, DANIEL JACOB
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 101ST PL S APT 711
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3541
Mailing Address - Country:US
Mailing Address - Phone:805-248-8807
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 180
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1077
Practice Address - Country:US
Practice Address - Phone:918-960-7852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA557-99-5716Medicaid