Provider Demographics
NPI:1508829185
Name:RODRIGUEZ, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
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 1:742 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3839
Mailing Address - Country:US
Mailing Address - Phone:909-376-4438
Mailing Address - Fax:909-881-7330
Practice Address - Street 1:7965 SIERRA AVE STE E
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3329
Practice Address - Country:US
Practice Address - Phone:909-356-4459
Practice Address - Fax:909-355-4261
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA118228OtherPECOS
CA1508829185Medicaid
CA00A784100Medicare ID - Type Unspecified