Provider Demographics
NPI:1811410541
Name:RODRIGUEZ, JONNATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONNATHAN
Middle Name:
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 1:755 DUNN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1753
Mailing Address - Country:US
Mailing Address - Phone:314-731-4222
Mailing Address - Fax:314-731-4020
Practice Address - Street 1:755 DUNN RD STE 110
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1753
Practice Address - Country:US
Practice Address - Phone:314-731-4222
Practice Address - Fax:314-731-4020
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017015272207R00000X
MO2020024095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty