Provider Demographics
NPI:1649231275
Name:RODRIGUEZ, UBALDO R (MD)
Entity Type:Individual
Prefix:
First Name:UBALDO
Middle Name:R
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 1:1600 HERITAGE LNDG
Mailing Address - Street 2:STE 215
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8489
Mailing Address - Country:US
Mailing Address - Phone:636-939-4200
Mailing Address - Fax:636-939-4204
Practice Address - Street 1:1600 HERITAGE LNDG
Practice Address - Street 2:STE 215
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-8489
Practice Address - Country:US
Practice Address - Phone:636-939-4200
Practice Address - Fax:636-939-4204
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29894208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505243003Medicaid
MO505243003Medicaid
MO174713595Medicare PIN