Provider Demographics
NPI:1699031534
Name:RODARTE, JOSE R (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:R
Last Name:RODARTE
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 1:839 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:520-884-9287
Practice Address - Street 1:839 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2819
Practice Address - Country:US
Practice Address - Phone:520-792-9890
Practice Address - Fax:520-884-9287
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ158936Medicaid
AZZ191342Medicare PIN