Provider Demographics
NPI:1417977992
Name:RODRIGUES, MARK JERVIS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JERVIS
Last Name:RODRIGUES
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1140 W LA VETA AVE
Mailing Address - Street 2:SUITE #470
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:714-245-9900
Mailing Address - Fax:714-245-9901
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:SUITE #470
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-245-9900
Practice Address - Fax:714-245-9901
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA107415207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A463400Medicaid
CA330801446OtherEMPLOYER ID
CAB12564Medicare UPIN
CAA46340Medicare PIN