Provider Demographics
NPI:1730295395
Name:RODRIGUEZ, ELIAS S (MD)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:S
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 1:10 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-4202
Mailing Address - Country:US
Mailing Address - Phone:831-722-4016
Mailing Address - Fax:831-722-7756
Practice Address - Street 1:10 W 5TH ST
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4202
Practice Address - Country:US
Practice Address - Phone:831-722-4016
Practice Address - Fax:831-722-7756
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G776691Medicaid
CA110230847OtherRAILROAD MEDICARE
CA00G776691Medicaid
CAF69836Medicare UPIN