Provider Demographics
NPI:1184623886
Name:RODRIGUEZ, JACK JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:JOSEPH
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:NATCHEZ
Other - Middle Name:ONCOLOGY
Other - Last Name:CLINIC INCORPORATED
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:400 S COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-3506
Mailing Address - Country:US
Mailing Address - Phone:601-442-9210
Mailing Address - Fax:601-442-7409
Practice Address - Street 1:106 JEFFERSON DAVIS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5104
Practice Address - Country:US
Practice Address - Phone:601-442-9210
Practice Address - Fax:601-442-7409
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15252207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015568Medicaid
MS00123444Medicaid
900003448Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MS09015568Medicaid
MS00123444Medicaid