Provider Demographics
NPI:1366508160
Name:ROD, JOE L (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:L
Last Name:ROD
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 1:2020 FOREST AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4805
Mailing Address - Country:US
Mailing Address - Phone:408-993-9511
Mailing Address - Fax:408-993-9559
Practice Address - Street 1:2020 FOREST AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4805
Practice Address - Country:US
Practice Address - Phone:408-993-9511
Practice Address - Fax:408-993-9559
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29563Medicare UPIN
CA00A423661Medicare ID - Type Unspecified