Provider Demographics
NPI: | 1467667774 |
---|---|
Name: | RODRIGUEZ, CRAIG PAUL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CRAIG |
Middle Name: | PAUL |
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: | 166 4TH ST. E. |
Mailing Address - Street 2: | STE. 100 |
Mailing Address - City: | ST. PAUL |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55101-1421 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 651-292-2000 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 250 THOMPSON ST. |
Practice Address - Street 2: | |
Practice Address - City: | ST. PAUL |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55102-2370 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-292-2000 |
Practice Address - Fax: | 651-292-2136 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-11 |
Last Update Date: | 2019-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 63830 | 2085R0202X |
OH | 35.093532 | 207UN0901X, 207UN0902X, 207UN0903X, 2085B0100X, 2085D0003X, 2085H0002X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0001X, 2085R0203X, 2085R0204X, 2085U0001X, 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No | 207UN0901X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology |
No | 207UN0902X | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
No | 207UN0903X | Allopathic & Osteopathic Physicians | Nuclear Medicine | In Vivo & In Vitro Nuclear Medicine |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
No | 2085D0003X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
No | 2085H0002X | Allopathic & Osteopathic Physicians | Radiology | Hospice and Palliative Medicine |
No | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
No | 2085N0904X | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
No | 2085P0229X | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No | 2085R0203X | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 1467667774 | Medicaid | |
PA | 1025450200001 | Other | PA MEDICAID |
OH | 2951284 | Medicaid | |
OH | P00880296 | Other | RR MEDICARE (RAILROAD) |