Provider Demographics
NPI:1821599358
Name:RODRIGUEZ, JILL STEPHANIE (OD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:STEPHANIE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9409 BOWMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-5023
Mailing Address - Country:US
Mailing Address - Phone:323-490-0580
Mailing Address - Fax:
Practice Address - Street 1:1509 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-3866
Practice Address - Country:US
Practice Address - Phone:213-250-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33835-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist