Provider Demographics
NPI:1710607304
Name:RODRIGUEZ, MARTIN EMIGDIO
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:EMIGDIO
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 BEWLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-4630
Mailing Address - Country:US
Mailing Address - Phone:209-262-8222
Mailing Address - Fax:
Practice Address - Street 1:2935 4TH ST
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-3222
Practice Address - Country:US
Practice Address - Phone:209-531-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty