Provider Demographics
NPI:1629178975
Name:RODRIGUEZ, MARLENE (MD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-2819
Mailing Address - Country:US
Mailing Address - Phone:520-792-9890
Mailing Address - Fax:
Practice Address - Street 1:5301 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2805
Practice Address - Country:US
Practice Address - Phone:520-319-0727
Practice Address - Fax:520-319-0752
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84528208000000X
AZ42628208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP71021FOtherFPACT
CAZZZ29799ZOtherFQHC MEDICARE PART B
CAFHC71021FMedicaid
CA55-1975OtherFQHC MEDICARE PART A