Provider Demographics
NPI:1467423525
Name:RODRIGUEZ, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN CARLOS
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 1:3955 BONITA RD
Mailing Address - Street 2:BUILDING E
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1230
Mailing Address - Country:US
Mailing Address - Phone:800-290-5000
Mailing Address - Fax:619-409-6541
Practice Address - Street 1:3955 BONITA RD
Practice Address - Street 2:BUILDING E
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-1230
Practice Address - Country:US
Practice Address - Phone:619-409-6517
Practice Address - Fax:619-409-6541
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76332208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA76332OtherMD LICENSE
CAA76332OtherMD LICENSE