Provider Demographics
NPI:1760470561
Name:RODRIGUEZ, JORGE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5413 CRENSHAW RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3143
Mailing Address - Country:US
Mailing Address - Phone:713-477-2283
Mailing Address - Fax:713-475-5986
Practice Address - Street 1:5413 CRENSHAW RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3143
Practice Address - Country:US
Practice Address - Phone:713-477-2283
Practice Address - Fax:713-475-5986
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3512208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114519503Medicaid
TX89X760OtherPTAN
TXD67662Medicare UPIN