Provider Demographics
NPI:1891148854
Name:RODRIGUEZ MORENO, JOSE ILDEFONSO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ILDEFONSO
Last Name:RODRIGUEZ MORENO
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 1:2900 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8458
Mailing Address - Country:US
Mailing Address - Phone:541-789-5790
Mailing Address - Fax:
Practice Address - Street 1:2900 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8458
Practice Address - Country:US
Practice Address - Phone:541-789-5790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2677072084N0402X
ORMD2020772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology