Provider Demographics
NPI:1639266141
Name:RODRIGUEZ-ELLIS, EVA BERGADO (MD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:BERGADO
Last Name:RODRIGUEZ-ELLIS
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 1:1403 LOMITA BLVD STE 305
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2085
Mailing Address - Country:US
Mailing Address - Phone:310-325-4344
Mailing Address - Fax:310-325-0594
Practice Address - Street 1:1403 LOMITA BLVD STE 305
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2085
Practice Address - Country:US
Practice Address - Phone:310-325-4344
Practice Address - Fax:310-325-0594
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA033241208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD34038OtherLABCORP