Provider Demographics
NPI:1568778306
Name:RODRIGUEZ MD, LLC
Entity Type:Organization
Organization Name:RODRIGUEZ MD, LLC
Other - Org Name:RODRIGUEZ MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NEVILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-888-2848
Mailing Address - Street 1:771 OLD NORCROSS RD
Mailing Address - Street 2:TERRACE PARK MEDICAL CENTER; SUITE 120
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4386
Mailing Address - Country:US
Mailing Address - Phone:770-670-6920
Mailing Address - Fax:770-670-6927
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:TERRACE PARK MEDICAL CENTER; SUITE 120
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4386
Practice Address - Country:US
Practice Address - Phone:770-670-6920
Practice Address - Fax:770-670-6927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003105719AMedicaid
GA202G701655Medicare PIN