Provider Demographics
NPI:1982038592
Name:RODRIGUEZ, JOSE LUIS (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 S STANFIELD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2374
Mailing Address - Country:US
Mailing Address - Phone:937-440-7788
Mailing Address - Fax:937-440-7177
Practice Address - Street 1:31 S STANFIELD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2374
Practice Address - Country:US
Practice Address - Phone:937-440-7788
Practice Address - Fax:937-440-7177
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH262261Medicare PIN
OH0110140Medicare PIN