Provider Demographics
NPI:1821035429
Name:RODRIGUEZ, JORGE O (DO)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:O
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 ATLANTA RD SE STE 107
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6431
Mailing Address - Country:US
Mailing Address - Phone:470-956-0330
Mailing Address - Fax:678-842-5525
Practice Address - Street 1:4441 ATLANTA RD SE STE 107
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6431
Practice Address - Country:US
Practice Address - Phone:470-956-0330
Practice Address - Fax:678-842-5525
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0096-01707207Q00000X, 207QS0010X
ARE-5890207Q00000X, 207QS0010X
GA63947207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174644003Medicaid
NC1021WOtherBCBS
NC1021WOtherBCBS
AR174644003Medicaid
AR5H297Medicare PIN