Provider Demographics
NPI:1245259647
Name:RODRIGUEZ, RUSSELL GERALD (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:GERALD
Last Name:RODRIGUEZ
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 1:2100 POWELL ST
Mailing Address - Street 2:STE 920
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9100
Practice Address - Street 1:3901 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6200
Practice Address - Country:US
Practice Address - Phone:925-779-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84370207P00000X
HIA84370207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A843700Medicaid
CAI26544Medicare UPIN
CA00A843701Medicare PIN