Provider Demographics
NPI:1245299916
Name:RODRIQUEZ, GERARDO R (MD)
Entity type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:R
Last Name:RODRIQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3501 COLBY AVE APT 311
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4796
Mailing Address - Country:US
Mailing Address - Phone:509-595-0009
Mailing Address - Fax:509-336-7389
Practice Address - Street 1:835 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5512
Practice Address - Country:US
Practice Address - Phone:509-336-7388
Practice Address - Fax:509-336-7389
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038146207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG96469Medicare UPIN
WAG8855531Medicare PIN