Provider Demographics
NPI:1356322051
Name:RODRIGUEZ, ANGEL (MD)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
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:P O BOX 3488, DEPT 05-061
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:662-665-0457
Mailing Address - Fax:662-665-0458
Practice Address - Street 1:401 ALCORN DR
Practice Address - Street 2:STE 1A
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9071
Practice Address - Country:US
Practice Address - Phone:662-665-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11295207L00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015456Medicaid
MS00015456Medicaid
MS0500004169Medicare ID - Type Unspecified