Provider Demographics
NPI:1790883064
Name:RODRIGUEZ, GREGORIO LERMA (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORIO
Middle Name:LERMA
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 1:1403 E MARSHALL ST
Mailing Address - Street 2:1403 E MARSHALL STREET
Mailing Address - City:CHARLESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63834-1446
Mailing Address - Country:US
Mailing Address - Phone:573-683-2327
Mailing Address - Fax:573-683-2373
Practice Address - Street 1:1403 E. MARSHALL STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MO
Practice Address - Zip Code:63834
Practice Address - Country:US
Practice Address - Phone:573-683-2327
Practice Address - Fax:573-683-2373
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33173207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11432OtherBCBS
MO863024OtherFIRST HEALTH
MO200006500Medicaid
MO863024OtherFIRST HEALTH
A11877Medicare UPIN
MO200006500Medicaid