Provider Demographics
NPI:1679709539
Name:RODRIGUEZ, ETIENNE JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:ETIENNE
Middle Name:JOSE
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 1:5471 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4114
Mailing Address - Country:US
Mailing Address - Phone:770-481-0889
Mailing Address - Fax:770-481-0986
Practice Address - Street 1:5471 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-4114
Practice Address - Country:US
Practice Address - Phone:770-481-0889
Practice Address - Fax:770-481-0986
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81672207Q00000X
NC2018-02700207Q00000X
CAC159178207Q00000X
VA0101265867207Q00000X
GA067979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125394BMedicaid
GA003125394AMedicaid
GA003125394CMedicaid
SCGA1345Medicaid
GA202I089221Medicare PIN
GA003125394BMedicaid
GA202I080469Medicare PIN
GA20208I9220Medicare PIN