Provider Demographics
NPI:1558825331
Name:RODRIGUEZ, MARTIN SETH
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:SETH
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 S CONLON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-4402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1481 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5416
Practice Address - Country:US
Practice Address - Phone:909-361-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA167G00000XMedicaid