Provider Demographics
NPI:1871815597
Name:GREGORIO L. RODRIGUEZ, M.D., P.C.
Entity Type:Organization
Organization Name:GREGORIO L. RODRIGUEZ, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-683-6066
Mailing Address - Street 1:P.O. BOX 394
Mailing Address - Street 2:1403 E. MARSHALL STREET
Mailing Address - City:CHARLESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63834
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200006500Medicaid
MO200006500Medicaid
MO000009405Medicare PIN
MOA11877Medicare UPIN