Provider Demographics
NPI:1922067875
Name:RODRIGO, IRANDATHY (MD)
Entity Type:Individual
Prefix:
First Name:IRANDATHY
Middle Name:
Last Name:RODRIGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 CRUSE RD
Mailing Address - Street 2:STE. C-2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2750
Mailing Address - Country:US
Mailing Address - Phone:678-225-5540
Mailing Address - Fax:678-225-5541
Practice Address - Street 1:2522 CRUSE RD
Practice Address - Street 2:STE. C-2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2750
Practice Address - Country:US
Practice Address - Phone:678-225-5540
Practice Address - Fax:678-225-5541
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08CBCQBMedicare PIN
G35161Medicare UPIN