Provider Demographics
NPI:1679848626
Name:RODRIGUEZ, JOSE ALBERTO (IDC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALBERTO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3915
Mailing Address - Country:US
Mailing Address - Phone:619-934-0582
Mailing Address - Fax:
Practice Address - Street 1:33000 NIXIE WAY
Practice Address - Street 2:BLDG 50 SUITE 245
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92147-5109
Practice Address - Country:US
Practice Address - Phone:619-524-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman