Provider Demographics
NPI:1760030712
Name:RODRIGUEZ, LUIS FERNANDO
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
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 1:5001 S COOPER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5993
Mailing Address - Country:US
Mailing Address - Phone:866-367-8768
Mailing Address - Fax:
Practice Address - Street 1:6801 OAKMONT BLVD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3903
Practice Address - Country:US
Practice Address - Phone:866-367-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program