Provider Demographics
NPI:1841209236
Name:RODRIGUEZ, PAUL L (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
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 1:4713 N PORTWEST CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67204-2356
Mailing Address - Country:US
Mailing Address - Phone:316-729-5517
Mailing Address - Fax:
Practice Address - Street 1:4713 N PORTWEST CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67204-2356
Practice Address - Country:US
Practice Address - Phone:316-729-5517
Practice Address - Fax:316-729-5655
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101662085R0202X
FLME902622085R0202X
KS04-14664208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSBCBS OF KSOtherBCBS IND OF KS 000105163
OK248522505OtherMEDICARE
OK7016639OtherAETNA
OKP00272804OtherRR MEDICARE #
OK100206250BMedicaid
KS105163Medicare PIN
OK100206250BMedicaid